What are the suggestionsn on healthcare?

[francoHFW]

GD Pub dupes. France NHC is rated#1, costs about 10% of GDP. Ours is #38, costs 18% and skyrocketing, 45k deaths, 750k bankruptcies. Absolute idiocy.

 

[dblack]

...Socialized medicine at some point is going to have to butt heads with individual liberty and that's going to be tough for a country like ours who prides itself on individual liberty. If state run, they will have to control costs. Which means they will have to at some point essentially tell people what they can and can't do as it effects the cost of paying for people's health care. If you're going to insist that government needs to administer this, by way of funding through ME, the taxpayer. Then you better be damn sure I'm going to want a say in how you live your life. What a person most certainly doesn't have a right to do is waste someone elses money. I have tried to ask those in favor of government single payer if they are okay with giving the rest of society the right to dictate how they live. As you can imagine it's been rather quiet.

This is certainly the most troubling aspect of socializing it in my view. Especially when you consider that most of the proponents are so eager to disregard the idea of limited government.

 

[francoHFW]

"Liberal Fascism" is absolute drivel- The Economist...You are a brainwashed Beckbot. LOL!!

 

[Wry Catcher]

You're forgetting the cost to provide medical treatment to those who can't pay for treatment, those who choose not to or are not permitted to buy health insurance (pre-existing condition) and those who must sell their home to pay for care. You also ignore the loss of productivity, the higher cost of delay and the ability of Universal Preventable Health Care can slow down a pandemic or the transmission of communicable disease.

No I'm not forgetting about it at all. I'm trying to bring those costs down. One of the best ways to do that is for the consumer to get involved with the product they're consuming. Let's take each of the groups you mention one at a time:

Those that can't pay for it: Expand medicare to this group of people.

Those who choose not to: if you choose not to engage in preventative care for yourself, J. Q. Taxpayer certainly shouldn't be on the hook for the consequences of that. We need to get away from this overly romanticized idea that all life is sacred and that it's cruel to allow others to suffer. A brutal reality of our world is that it's probably over populated and is getting even more so. Let's not waste time and other people's money trying save those who appear to not be interested in saving themselves.

Those who have to sell their house:? That's a little confusing. One shouldn't have to sell their house to pay for preventative care. It doesn't cost that much.

Lost productivity? I'm not sure what you mean by that. Who is going to be less productive?

Sorry, sometime when I try to be brief I make leaps. My point is there is no safety net for the responsible citizen hit with a catestropic illness/injury when his/her policy has reached it's limit. I see two necessary solutions: 1) Universal Preventative Health Care; 2) a no frills public option with services provided by state/county hospitals & clinics.

I suggest you reread your post above and consider the real world consequences. You've never stuck me as one of the wackos - this post is out there in my opinion.

We are less productive when employees and managers, etc. miss work as a result of illness whatever the etiology.

 

[Bern80]

Let's skip the metaphors and deal with real world facts. There is no reason a private provider can't offer a no frills policy, I never said they could not. A public option in my example provides medical insurance at public hospitals, provided by employees of county or state government. Generally no private rooms, no fancy art, no piano in the lobby. No frills; simply good basic medical treatment.

Actually it has been my experience that it's the state funded hospitals that have the extra frills. It should intuitively makes sense that is the case since the consumer of the product is so far removed from the costs of services at hospitals funded that way. But you do essentially admit there is a demand for more basic care and facilities?

Let's answer that by looking at the purpose of a private business. To make money right? Of course. HOW does a private business make money? By doing what their customer's want. That's business at the most basic level. That's the only way the relationship between consumer and service provider survives over time. The consumer get's what they want and compensate the provider for providing it. Private employees are incentivized to provide what people want. State employees are not. Private employees are incentivized to deliver quality to retain customers. State employees are not. I don't know how more basic to make it. The private sector is better suited for meeting people's needs because it's in their financial best interest to do so. That isn't true of state employees. Since a customer isn't going to take their money elsewhere they have less incentive to maintain quality. So why wouldn't a hospital jump at the chance to not waste money on all those extras if there's not demand for it? Answer: Because the consumer isn't paying for them. Insurance companies are paying for them or tax payers are indirectly paying for them. Or in some cases because those aesthetics are in fact demanded by the consumer. Many patients associate a utilitarian look with unfriendliness or uncleanliness.

 

[PoliticalChic]

"Liberal Fascism" is absolute drivel- The Economist...You are a brainwashed Beckbot. LOL!!

Did you notice that I quoted books? Books that I have read, leaky.

And you?

Not so much....

...have you ever read a book?

So, it stands to reason that you have no way to refute any of the points in the post....
the Left loves folks like you, you know....the easily led.


Has Jodie Foster responded to your notes yet?

 

[Wry Catcher]

Let's skip the metaphors and deal with real world facts. There is no reason a private provider can't offer a no frills policy, I never said they could not. A public option in my example provides medical insurance at public hospitals, provided by employees of county or state government. Generally no private rooms, no fancy art, no piano in the lobby. No frills; simply good basic medical treatment.

Actually it has been my experience that it's the state funded hospitals that have the extra frills. It should intuitively makes sense that is the case since the consumer of the product is so far removed from the costs of services at hospitals funded that way. But you do essentially admit there is a demand for more basic care and facilities?

Let's answer that by looking at the purpose of a private business. To make money right? Of course. HOW does a private business make money? By doing what their customer's want. That's business at the most basic level. That's the only way the relationship between consumer and service provider survives over time. The consumer get's what they want and compensate the provider for providing it. Private employees are incentivized to provide what people want. State employees are not. Private employees are incentivized to deliver quality to retain customers. State employees are not. I don't know how more basic to make it. The private sector is better suited for meeting people's needs because it's in their financial best interest to do so. That isn't true of state employees. Since a customer isn't going to take their money elsewhere they have less incentive to maintain quality. So why wouldn't a hospital jump at the chance to not waste money on all those extras if there's not demand for it? Answer: Because the consumer isn't paying for them. Insurance companies are paying for them or tax payers are indirectly paying for them. Or in some cases because those aesthetics are in fact demanded by the consumer. Many patients associate a utilitarian look with unfriendliness or uncleanliness.

I could not disagree more with your comments I highlighted. This is pure bias not based on any data and likely used by you (and demagogues everywhere) as an issue to inflame those who were annoyed by their treatment at the Motor Vehicles Department or the wages and benefits of others. You continue the Right Wing efforts (no matter what you claim) of pitting citizen against citizen, an infamous and outrageous example of what's really wrong with American political discourse today.

 

[Bern80]

Sorry, sometime when I try to be brief I make leaps. My point is there is no safety net for the responsible citizen hit with a catestropic illness/injury when his/her policy has reached it's limit. I see two necessary solutions: 1) Universal Preventative Health Care; 2) a no frills public option with services provided by state/county hospitals & clinics.

Again I'm in pretty good position to answer that since I've had it happen. I had cancer when I was little and continue, at the age of 31, to deal with medical expenses related to it. I do occasionally get bills that are for more than what I can at the time afford. Even with insurance covering part of it. Most of the time I just call the hospital and ask them if they'll spread the bill out over a few months. They've never had a problem doing that.

We are less productive when employees and managers, etc. miss work as a result of illness whatever the etiology.

That's true, but employees already have pretty good incentive to prevent that themselves. For some missing work means not getting paid at all, so there's that incentive to stay healthy. For those that do have vacation most people try to save that to actually go on vacation. Not waste it being ill.

 

[Bern80]

Let's skip the metaphors and deal with real world facts. There is no reason a private provider can't offer a no frills policy, I never said they could not. A public option in my example provides medical insurance at public hospitals, provided by employees of county or state government. Generally no private rooms, no fancy art, no piano in the lobby. No frills; simply good basic medical treatment.

Actually it has been my experience that it's the state funded hospitals that have the extra frills. It should intuitively makes sense that is the case since the consumer of the product is so far removed from the costs of services at hospitals funded that way. But you do essentially admit there is a demand for more basic care and facilities?

Let's answer that by looking at the purpose of a private business. To make money right? Of course. HOW does a private business make money? By doing what their customer's want. That's business at the most basic level. That's the only way the relationship between consumer and service provider survives over time. The consumer get's what they want and compensate the provider for providing it. Private employees are incentivized to provide what people want. State employees are not. Private employees are incentivized to deliver quality to retain customers. State employees are not. I don't know how more basic to make it. The private sector is better suited for meeting people's needs because it's in their financial best interest to do so. That isn't true of state employees. Since a customer isn't going to take their money elsewhere they have less incentive to maintain quality. So why wouldn't a hospital jump at the chance to not waste money on all those extras if there's not demand for it? Answer: Because the consumer isn't paying for them. Insurance companies are paying for them or tax payers are indirectly paying for them. Or in some cases because those aesthetics are in fact demanded by the consumer. Many patients associate a utilitarian look with unfriendliness or uncleanliness.

I could not disagree more with your comments I highlighted. This is pure bias not based on any data and likely used by you (and demagogues everywhere) as an issue to inflame those who were annoyed by their treatment at the Motor Vehicles Department or the wages and benefits of others. You continue the Right Wing efforts (no matter what you claim) of pitting citizen against citizen, an infamous and outrageous example of what's really wrong with American political discourse today.

You can disagree all you want. That is basic established fact that's how it works. Do what your customer wants has historically shown to be the best way to make money while ensuring the longevity of a business. What you hilighted isn't political. It's basic psychology on human behavior and interaction. Are you really going to try to tell me with a straight face that you have the same incentive to treat me exactly the same way under these two scenarios;

1) I need a house built. We draw up plans and I agree to pay you upon completion and making sure that everything is to quality and specifications of the plans.

or

2)I need a house built. But due to my financial situation the government is going to pay for it instead of me.

You can't be that naive Wry.

 

[Political Junky]

Medicare for everyone, from cradle to grave.

 

[WatertheTree]

State ran health care. From top to bottom. State ran hospitals, clinics and so on. State paid doctors, nurses and everything else. Mandatory waivers of the right to sue. On the job training for as many positions as possible to hold costs low. Every patient and every treatment needs to be looked at from a 'remaining contribution to society/cost of treatment' perspective.

Private healthcare firms can continue to compete as they see fit.

The answers are out there people, we are the last industrialized nation to figure this out. We dont have healthcare because to many shitbags are making huge profits from the existing failed system.

This is pretty extreme. We're going to decide to treat people based on their "remaining contribution to society"? I find that repulsive. What about those born disabled? They'll have to forfeit healthcare from the beginning? The elderly will have used up their allotment? Who get's to decide someone's remaining contribution to society? And what if they do not live up to expectations? Do we go back and remove the liver we transplanted into them and give it to someone else? Who gets to decide what cost is worth how much "contribution"?

I dont think its that extreme. I am just dealing in something called REALITY. You know where just because we have the ability to do a 300k heart transplant doesnt mean that everyone should get one.

You want to outlive your usefullness to society? Then I suggest you get off your ass and make something of yourself so you can pay for private health care.

With regard to your pity on the disabled, disabled people can still contribute to society. If they cannot then it is unfortunate but everyone dies. Why would we spend unlimited amounts of dollars on an investment that will yeild zero results?

At some point we all need to put on our big boy pants and realize that everyone will die. That we cannot spend unlimited amounts of goods and services from society on investments that will never pay off. Its harsh, but it is REALITY. And you need a good strong dose of it.

 

[Greenbeard]

Obama's bill was horrible and is largely unpopular. Yet the fact still remains that something needs to be done. So what are the suggestions? How to we improve the health care situation in our country?

The biggest problem we have is that there are serious structural problems with our system as it current functions. You'll sometimes encounter the adage that "Every system is perfectly designed to get the results it gets," which fits well with the important insight that the system we've got is not designed to get the results we want. Given what we spend on it, a system that doesn't give us the outcomes we want is unacceptably low-value (value being the cost to quality ratio).

The Institute of Medicine has been beating this drum for well over a decade and if you're really interested in what a better functioning health care system might look like, it's worth closely reading this article: A User’s Manual For The IOM’s ‘Quality Chasm’ Report

To add to/build on/complement that article, I'd copy here a few items from a short wishlist for improving value in health care I laid out in another thread the other day:

• More emphasis on primary care and prevention, particularly through various advanced models of primary care that are gaining steam
• A more holistic philosophy of systems-minded, patient-centered care instead of the disjointed, impersonal mess (and all the havoc it wreaks) we have today
• Better use of information to support clinicians and improve care delivery: that covers a lot of ground, like point-of-care clinical studies, clinical decision supports, and easier access to health information and data for doctors at the point of care
• Better functioning markets with the right incentives (particularly for quality and efficiency) and meaningful price signals
• Development and proliferation of evidence-based clinical practice guidelines, which are in relatively short supply at present
• More integrated service delivery, a form of reorganization to provide better care more cheaply
• Potentially, all-payer rates to eliminate the potential for cost shifting or dumping and mute the impact of provider market power and provider consolidation on prices

 

[dblack]

The biggest problem we have is that there are serious structural problems with our system as it current functions. You'll sometimes encounter the adage that "Every system is perfectly designed to get the results it gets," which fits well with the important insight that the system we've got is not designed to get the results we want. Given what we spend on it, a system that doesn't give us the outcomes we want is unacceptably low-value (value being the cost to quality ratio).

The Institute of Medicine has been beating this drum for well over a decade and if you're really interested in what a better functioning health care system might look like, it's worth closely reading this article: A User’s Manual For The IOM’s ‘Quality Chasm’ Report

To add to/build on/complement that article, I'd copy here a few items from a short wishlist for improving value in health care I laid out in another thread the other day:

• More emphasis on primary care and prevention, particularly through various advanced models of primary care that are gaining steam
• A more holistic philosophy of systems-minded, patient-centered care instead of the disjointed, impersonal mess (and all the havoc it wreaks) we have today
• Better use of ...
  
  ...

I suppose you realize this, but this approach it is antithetical to free markets. Free markets don't 'design' systems of the sort required to impose the kinds of reforms you are suggesting. Which is why we don't talk about the automobile care 'system' or the national software development 'system'. Markets leave people free to decide for themselves how best to attend to their wants and needs. They can join a 'system' if they so desire, but if that system sucks, they can drop it and try something else.

The problems we face with health care are precisely because we've indulged the desire for centralized 'system'-ization. We've allowed health care to come under the control of cartel like interests that manipulate it to their ends. What we need is less 'system' and more freedom for health care consumers to find better solutions. Treating health care as a system which can be commanded and controlled by centralized authorities is the problem, not the solution.

 

[Defiant1]

Free-market....As with auto insurance, no mandates, select what you wish to be covered for, sell across state lines, and ..

Every state has minimum coverage requirements for auto insurance, and mandates every driver to have it. While I also disagree with mandates, I think comparing health care to auto insurance to maintain that position is flawed.

... Tort Reform:
While malpractice litigation accounts for only about 0.6 percent of U.S. health care costs, the fear of being sued causes U.S. doctors to order more tests than their Canadian counterparts. So-called defensive medicine increases health care costs by up to 9 percent, Medicare's administrator told Congress in 2005. "
Canada keeps malpractice cost in check - St. Petersburg Times

I think we discussed this in another thread. The real fire behind "defensive" medicine is the provider's interest in driving up the costs on the patient, and patient ignorance. Provider's cannot order any procedure that the patient does not consent to. The doctor can advise the patient submit to a test, but the patient can refuse. The doctor cannot force it on the patient. And once the doctor has advised the patient in a reasonable manner, he is no longer at risk for a malpractice claim.

So, the excuse that the medical business gives of defensive medicine is just that, an excuse. In truth, the medical business is in the habit of constantly upselling their customers, in order to increase revenues. Since patients are often either ignorant of their rights, swayed by fear, and/or ignorant about their general health, most patients scarcely put up resistance when the doctor says "we should do tests x, y, and z."

The mandates are to protect the other person. There are no government mandates to insure your own vehicle.

 

[Greenbeard]

I suppose you realize this, but this approach it is antithetical to free markets. [...]

The problems we face with health care are precisely because we've indulged the desire for centralized 'system'-ization.

Bizarre reaction, as "system" is not a particularly controversial word:

System (from Latin systēma, in turn from Greek σύστημα systēma, "whole compounded of several parts or members, system", literary "composition"[1]) is a set of interacting or interdependent components forming an integrated whole.

A system is a set of elements (often called 'components' instead) and relationships which are different from relationships of the set or its elements to other elements or sets.

The concept of interlocking elements forming a well-functioning system is not antithetical to markets, of course. In fact:

A market system is any systematic process enabling many market players to bid and ask: helping bidders and sellers interact and make deals. It is not just the price mechanism but the entire system of regulation, qualification, credentials, reputations and clearing that surrounds that mechanism and makes it operate in a social context.

 

[dblack]

The concept of interlocking elements forming a well-functioning system is not antithetical to markets...

The kind of 'system' that would be required to dictate the reforms you suggest would be, however. It's that urge to over-control things which has painted us into this corner in the first place.

 

[Inthemiddle]

I dont think its that extreme. I am just dealing in something called REALITY. You know where just because we have the ability to do a 300k heart transplant doesnt mean that everyone should get one.

And who are you, or anyone else, to say make the arbitrary decision that this person deserves it and this person doesn't?

You want to outlive your usefullness to society?

My life is mine alone.

Then I suggest you get off your ass and make something of yourself so you can pay for private health care.

Wait a second, you're advocating for state run health care, and your defending your suggestion with private insurance? Now you're being absurd.

With regard to your pity on the disabled, disabled people can still contribute to society. If they cannot then it is unfortunate but everyone dies. Why would we spend unlimited amounts of dollars on an investment that will yeild zero results?

You are getting dangerously close to fascism. Who the fuck are you or anyone else to decide whether a person is entitled to health care based on what "return on investment" their life can offer?

At some point we all need to put on our big boy pants and realize that everyone will die. That we cannot spend unlimited amounts of goods and services from society on investments that will never pay off. Its harsh, but it is REALITY. And you need a good strong dose of it.

Now, you're just making a nihilist argument. Which makes it all even more pathetic.

 

[Inthemiddle]

The concept of interlocking elements forming a well-functioning system is not antithetical to markets...

The kind of 'system' that would be required to dictate the reforms you suggest would be, however. It's that urge to over-control things which has painted us into this corner in the first place.

I think you might be misunderstanding Greenbeard. From what I gather he's saying that the industry itself needs to reform with a different philosophical approach to health care. The points he raises are actually very good ones, and are areas where the health care industry could certainly grow in order to provide a better product.

 

[dblack]

The concept of interlocking elements forming a well-functioning system is not antithetical to markets...

The kind of 'system' that would be required to dictate the reforms you suggest would be, however. It's that urge to over-control things which has painted us into this corner in the first place.

I think you might be misunderstanding Greenbeard. From what I gather he's saying that the industry itself needs to reform with a different philosophical approach to health care. The points he raises are actually very good ones, and are areas where the health care industry could certainly grow in order to provide a better product.

Perhaps you're right. I'll admit to some bias, and I was definitely making assumptions about implementation. How about we ask Greenbeard: Were your reforms suggestions for things you'd like to see members of the industry try (or not) on their own? Or were you thinking of some kind of government led initiative?

 

[Greenbeard]

If it's an either/or proposition, then we've already lost. Federal and state governments are major payers; if they don't play, then it won't work.

In Cutting Costs Through Better Care Delivery, I highlighted an article describing the approaches and processes that have helped Intermountain Healthcare to cut costs and improve quality. Intermountain is an (private) integrated delivery system (not my word, that's just what they're called) like Geisinger or the Mayo Clinic or Kaiser Permanente, which allows it to more seamlessly integrate different types of care, as well as payment and care delivery, for patients.

Though unfortunately it's behind a paywall, it's a great article that illustrates very well what a systems approach looks like (and why the more successful players in the broader health system have all embraced such approaches). But the authors also get to the point that payers--public and private--need to change the way they pay in order to foster the kinds of innovations Intermountain has pursued:

Aligning Financial Incentives

Quality improvement is innately a preventive strategy. It achieves most of its cost savings by improving care “upstream,” thereby avoiding “downstream” failures and their associated recovery costs. Most clinical savings stem from reduced hospitalizations, reduced emergency department visits, and reduced resource consumption within care delivery episodes. David Clark and coauthors provide specific examples of the cost savings that resulted from clinical improvement efforts at Intermountain.18 Such savings extend well beyond savings from administrative improvements.

Unfortunately, health care providers today are paid for precisely those care delivery episodes that quality improvement seeks to reduce. As Intermountain teams implemented clinical management, clinical outcomes improved and costs fell. However, our payments also fell—often even further than our operating costs. For example, although improvement in Intermountain’s appropriate elective induction rates saved the citizens of Utah more than $50 million per year through reduced payments, Intermountain’s costs fell by only about $41 million. Intermountain thus lost more than $9 million per year in operating margins. Implementing better care required us to invest in education, work-flow redesign, and new data systems. As we improved, the resources to drive further change disappeared. [...]

All of the [Affordable Care] act’s major initiatives to reform the care system—such as accountable care organizations and patient-centered medical homes—are intended to “bend the cost curve.” They reflect sophisticated forms of provider cost sharing, an approach that differs from the health maintenance organization in three major ways.

First, in the past twenty years we have seen great improvement in the science of clinical risk adjustment and quality measurement. Well-organized care delivery groups can apply that science to generate and use robust measures that lead to effective care management. Second, the groups charged with managing the care are clinical teams at the bedside, not distant health insurance companies. The third difference between the new organizational structures proposed in the Affordable Care Act and health maintenance organizations is a major advantage for the former: When a care delivery group reduces health care costs by improving clinical outcomes, some of those savings will flow back to the clinical teams that delivered better care. This aligns financial incentives with efforts to improve clinical quality.

Taken together, these policy changes are crucial. Truly “managed care” means “organized care”—care whose hallmarks include rich clinical and financial data that inform the decisions of clinical teams at the bedside; and clinical teams that employ patient-centered care processes leading to improved population health. Researchers must partner with practitioners to evaluate and demonstrate innovative financial alignment models. A central challenge for policy makers now is to align financial incentives and drive the transition to organized care systems that can provide “the best clinical result at the lowest necessary cost.”

That's an area where public payers can and should (and now are) play a big role, as should private payers (e.g. Blue Cross Blue Shield of Massachusetts now has the Alternate Quality Contract which hems along these lines).

When Dr. Don Berwick--the author of that excellent User’s Manual For The IOM’s ‘Quality Chasm’ Report , which again I highly recommend--was heading the Institute for Health Improvement, he started an initiative called the 5 Million Lives Campaign. Berwick's one of the foremost experts on quality improvement and patient safety and his organization was working with private providers to implement some of those systems approaches to slash the number of preventable deaths or other medical errors.

He's now in the public sector, essentially heading the public payers, and in that role he's doing the same thing he did in the private sector: convening hospitals, doctors, and lots of other players to get people work together in pursuit of patient safety. The new national effort is called the Partnership for Patients. I don't particularly care if the convening is being done from CMS instead of IHI, though now I suppose that makes this voluntary project a "government-led initiative." But it remains an important step in re-orienting the health system toward the patient (see one of the ten simple rules in that's User's Manual article: ("(6) Current: "Do no harm" is an individual responsibility. New: Safety is a system property. Patients should be safe from injury caused by the care system. Ensuring safety requires greater attention to systems that help to prevent and mitigate errors.")

You've also now got things like the public and private sector payers harmonizing their asks (and incentives) of physicians and hospitals to migrate to interoperable electronic health records. If you wade through that Cutting Costs through Better Care Delivery thread, you'll see that EHRs and appropriate use of data in general are crucial pieces of the puzzle.

If the health care system is going to be re-oriented toward patients and value then it's all hands on deck. You can't ignore the private payers and you can't freeze out the public payers. That's part of the reason for using the system concept: we've got a very complex set of interactions going on but we're not going to get lasting positive change unless all of the elements are working harmoniously toward that.

Again, it returns to "Every system is perfectly designed to get the results it gets." Anyone thinking about the questions raised in the OP needs to consider what the results will be (and what they want them to be) for a given approach, taking into account the characteristic features of health care and health insurance markets, as well as the realities of service delivery.