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US Healthcare, revisited

Discussion in 'Issues Around the World' started by Steve, Dec 3, 2002.

  1. Steve

    Steve Is that it, then?

    Mospaw's post on US Healthcare in the America's form got me to thinking.

    The current "system" of healthcare available in the US is a hodgepodge of private and publicly funded insurerers, hospitals, providers, etc. It has developed over the years in reaction to political pressure, changing business practices, and a variety of other factors. Before we attempt to figure out to fix something that is so badly broken, maybe we need to take a step back, examine the wreckage, and try to decide how it should look before we break out the tools. Here are some thoughts on what a nationwide healthcare system in the US could look like:

    <u>Point 1</u>
    The system must be oriented toward prevention and early detection. It is far cheaper and more effective to prevent illness than it is to treat it.

    This means that all children are afforded immunizations, well-baby checkups, eye and dental care, through the age of 18, regardless of the family's ability to pay for such care. Nutrition programs must be included in this coverage, as well. Studies have shown that children who are adequately fed have fewer health problems later in life and are more likely to be successful in school.

    Besides offering children the basic preventive care to get them started out right, adults must be offered weight management programs, smoking cessation programs, incentives to participate in regular exercise programs, and information and education on avoiding health risks.

    <u>Point 2</u>
    The system must be market-driven. A free economic environment is one that will foster growth and research. It will reward skilled practictioners and facilities. It will provide incentives for people to enter the medical profession.

    A market-driven health care system can, if managed properly, create an environment in which various entities are competing to offer the highest level of care at the lowest possible cost. It works in other industries, including service industries; there is no reason it cannot be made to work in the health care industry.

    <u>Point 3</u>
    A health care system must be based on medical necessity. Simply put, that means that doctors make the decisions regarding a patient's treatment plan, in consultation with the patient and relevant specialists. Additionally, once a patient's physician has developed a plan of care, everthing within that plan is automatically covered. No "unreimbursed expenditures" will be incurred by the patient.

    By all means, a system of peer review should be implemented for non-standard plans, or for ones that could incur extraordinary costs. Such peer review, however, must be limited to other medical professionals whose sole responsibility is merely to judge whether or not the patient's physician has made reasonable and prudent decisions regarding the plan of care and that no other feasible, medically viable alternatives exist.

    <u>Point 4</u>
    This health care system must be managed for quality. Credentialing and ongoing training for all health care professionals should be mandatory. All such professionals should only be required to work reasonable shifts, no more than 12 consecutive hours per day, or 24 consecutive hours every three days.

    A nationwide, mandatory system of supervised probation with the potential for de-licensing/de-credentialing must be instituted to monitor and correct the performance of poorly-performing medical professionals.

    <u>Point 5</u>
    A nationwide healthcare system must foster and encourage basic medical research and development. So-called "orphan drugs" and highly specialized apparatus should be subsidized in some fashion by the government. Corporations performing research should be able to write off reasonable costs associated with "dead ends". At the same time, prescription drug prices must come down. This could be done by extending the time period a company holds on a drug patent, so that a greater amount of time is available to recoup the initial investment and make a profit; or, the government could be the sole-source purchaser of drugs, negotiating directly with the manufacturers to gain the cheaper prices available when mass quantities are involved.

    <u>Point 6</u>
    This system must be single-payor. Vast amounts of waste and duplication are built in to the current health care claims processing systems. Most practices and hospitals employ any number of people whose sole responsibility is to coordinate claims payments between various plans.

    One payor, one standard set of transactions, with incentives to automate and process those transactions electronically.

    <u>Point 7</u>
    Lastly, this system must be universally available. Office co-pays must be large enough to discourage frivolous use of the system, but small enough as not to pose a burden. Premiums should be based on ability to pay and adjusted according to the need for prescription medications. Annual deductibles should be non-existent for illness-related treatment, and reasonable to cover injury-related treatment.

    Those are my thoughts on the form a nationwide healthcare system could take. So, what have I left out?
  2. Sierra Mike

    Sierra Mike The Dude Abides Staff Member

    Points 1 and 7 will never make it past the drug company lobbyists. :)

  3. mikeky

    mikeky Member

    Nice outline of where we need to get (I'm still serious about that stevent for Congress thing).
  4. RRedline

    RRedline Veteran MMember

    Very nice points, but I have to take issue with part of point number 7. Why would premiums for healthcare be based on ability to pay*? My car insurance isn't based on my annual income. When I buy groceries at the supermarket, I don't have to provide my most recent tax forms to show them how much money I made last year...so they can determine how much I must pay for the products. How about clothing? There are many necessities besides healthcare, so why should that be treated any differently?

    And imagine how much abuse there would be! I can't even imagine how the insurance companies would keep track of everyone's ability to pay*. Workers Compensation policies require audits each year in order to adjust the previously paid premiums which were based on estimated annual payrolls. It is very time consuming and adds overhead costs to insurance companies. I know, I know...fuck the insurance companies. They are evil, blah blah blah. I work for one, so I see things much differently than most of you. ;)

    Other than taxes, I don't believe the price for any product or service should be based on one's ability to pay*. If healthcare was paid entirely by the government in exchange for higher taxes though, I guess it would in fact work that way.

    I can see us moving towards socialized medicine, but it would probably be done poorly and inefficiently just like so many programs run by the government. And those who are least able to pay* for healthcare are the ones who will rally for it.

    * Ability to pay is defined as spending one's money(often provided by tax payers) on beer and cigarettes instead of health insurance.
  5. Steve

    Steve Is that it, then?

    To address your points, RRedline, I don't see any insurance company playing any role, except possibly as contract administrator, in a nationwide system. They may continue to provide private-pay insurance to those who desire it, but would be effectively cut out of my plan, completely.

    Regarding ability to pay, first of all, the IRS knows what you make, so deciding premium amounts should be relatively easy and also subject to adjustment each year, if income fluctuates, either up or down.

    As to your main contention, "ability to pay" is a key facet of universal availability. From a social perspective, is it not desirable that the "haves" should help out the "have nots"? Isn't there room in our society for charity, for helping out the needy?

    From a practical perspective, poor people are the largest segment of the population that utilize emergency room services, which are the most expensive medical services available. The poor people do this because they cannot afford health insurance so they typically wait until their symptoms are unbearable and then seek treatment via emergency rooms. Need I point out this is the most costly and ineffective way to provide treatment?

    Far better, in my opinion, that universal coverage be made available, with payment for such coverage dependent upon one's income. The overal cost savings would, I'm certain, be passed on.
  6. RRedline

    RRedline Veteran MMember

    Perhaps I misunderstood the overall makeup of the system you proposed. So who exactly pays the healthcare providers? I mean people like doctors, nurses, surgeons, hospital staff, pharmaceutical companies including researchers, etc., etc. Would all the bills be paid by the government? And if so, then why even charge anyone a "premium" for anything? Why not just increase federal taxes accordingly to offset the costs? When I see the word premium, I usually think of insurance companies.

    I would like to point out one thing. It is not the poorest of the poor who have no health insurance. I know a few people whose incomes are so low that they and/or their children get state health insurance. It is the people who are not poor enough for all the free stuff but who are living paycheck to paycheck who are going without medical insurance.

    My neighbor(the ones who steals from SSI every month because she's too lazy to work) has free insurance from the state of Pennsylvania, and her coverage is much better than mine or my partner's. Last year when he was all busted up from a motorcycle accident, the only pain medication that worked for him was costing us $100 per refill. My neighbor was inside one day and picked up the bottle to see what he was taking, and she said something like, "Oh, this is good stuff. I use it for my back." I asked her how she could afford it, and she said it was free for her(well, like a $1 copay). My partner ended up smoking marijuana every night just so he could fall asleep, and my neighbor gets "the good stuff" for free?
  7. Steve

    Steve Is that it, then?

    Yes, the government would be the single payor. I hesitate to recommend increasing taxes to pay for such a health care system. Any tax, once instituted, has a way of increasing itself, over time. Besides, there still needs to be a strong element of personal responsibility. One method of keeping it would be to make sure that people see and feel the impact of their premium payment every month. There is more of an incentive, at a macro level, to control costs when one is directly responsible for paying those costs.

    You are absolutely correct in your observation about the so-called "working poor" being the ones who currently suffer the worst. Under my scenario, they would still pay something, although far less than you or I might, but the difference is that they would now have access to quality healthcare.

    I did not address the issue of abuse because, quite frankly, I'm not quite certain how. Abuse of the system, as you describe, should be penalized under criminal statutes. That is not a component of any health care system, of course. The difficulty as I see it lies in determining when such abuse is occurring.

    Doctors who are reimbursed through existing state-run plans are paid so little for their effort and time that there is no incentive for them to ask the kinds of questions and perform the kinds of tests necessary to reveal abuse. If a patient complains of chronic back pain, they prescribe medication, and move on to the next warm body.

    My proposal would, I hope, have the effect of paying physicians for the value of their services, thus making it less likely that we would have "assembly line" medical services that foster abuse.
  8. Stiofan

    Stiofan Master Po

    Problem is, you can't have the government pay and the doctors determine the course of treatment. There won't be enough money. Hell, Medicare is so screwed up now, most seniors can't even find a doctor willing to take them on as a new patient. My father couldn't find one where he moved to last year, after calling 17 in the phone book. He finally called his doctor down in L.A., who literally had to call a doctor he knows in my dad's town (45,000 population) and beg the guy to take my dad on. My mom had the same problem up in Idaho. The government won't reimburse the doctors what they need to make this work.
  9. LissaKay

    LissaKay Oh ... Really???

    One thing that the medical profession needs to get away from is the idea that every single person needs every single treatment possible for every single ailment. This makes for a great deal of waste, overspending and reduction in available resources. Part of the onus of this is also on the healthcare consumer, but we as a society have come to believe that the doctor is omniscient. The tough part will be to decide when to say enough is enough and draw the line at what is "too much."

    I used to be a paramedic and prior to that, an EMT for a total of eight years in the field. During that time, I saw an incredible amount of waste and overuse of healthcare resources. In addition to answering emergency calls, we were often called upon to transport non-emergency cases. The majority of these were the elderly. And most of the transports were from the hospital to a nursing home or their residence. In second place were the transports for kidney dialysis.

    What bothered me though, were the elderly that were being transported to and from radiation and chemotherapy sessions. Think about it. You are in your golden years, and there are but few of them left. You've lived your life, raised your family and retired. Then cancer is diagnosed. The doctor is recommending numerous treatment options which include radiation, chemotherapy, and perhaps surgery. What would you do at the age of 80? 85? 90?

    I know I would opt for a generous prescription of pain killers and start preparing for the end. I would live as much life as I could, make amends where due and say my good-byes. I doubt I would spend my remaining days riding in an ambulance back and forth three times a week to be taken in to lie on a cold, hard table while beams of radiation were shot through my body. I would not relish going in on the other two weekdays to have a needle stuck in my arm so poisonous chemicals could be flooded into my veins.

    However, those treatment options are, and must be offered to anyone regardless of their age. Doctors cannot discriminate against elderly patients and deny care because they are "about to die anyway." But honestly, is this fair to anyone?

    Cancer treatment is expensive, resource intensive and time consuming. Transport alone for one radiation treatment takes an ambulance out of service for at least one hour, often longer if the patient lives far from the facility. The radiation treatment room can be used by a limited number of people, and in many parts of the country there are waiting lists to get in. Some drugs used for chemotherapy are in short supply and are horrendously expensive.

    I know it sounds cruel and callous to even suggest that the elderly be denied cancer treatment, but is it any less cruel to deny treatment to other people because the resources, finance and time considerations are already overwhelmed? This very idea is a demon I wrestle with in my own conscience but when this country is faced with the shortage of availability of healthcare for all of its citizens, there has to be a line drawn somewhere.

    I have the same tortured opinion about heroic or even extreme measure that are taken to keep the terminally ill alive. Until my own dying day I will remember vividly a patient I transported once a week for nearly six months. She was the prettiest little redhead 8 year old girl. She had an inoperable brain tumor that was predicted to kill her within a year, if that long. She went through the radiation and chemo, and at the time I was taking care of her, she was going for physical therapy. Or rather, she would go on the days her body wasn't racked by nearly constant seizures, or when she wasn't doubled over with nausea and vomiting from all the medications she was taking. She lived 8 of the 12 months that were predicted for her. If there had been but a glimmer of hope for this child, I would have transported her anywhere, but why not leave her at home in her familiar surroundings? Why haul her all over the place just so she can practice holding a crayon and fitting shaped blocks into the correct slots? Was it to prepare her for the next round of chemo and radiation treatments that were, at best, a futile effort?

    At the age of 29, my brother was seriously head injured. He was placed on life-support and at first there was hope. However, in the following hours his condition deteriorated, and the doctors came to the conclusion that he was in all likelihood brain dead. My parents were in no emotional shape to make any kind of decision, so I did. I told them to shut off the machines and let him go. Even if he were to recover the ability to breathe on his own, he would have required years and years of intensive therapy, surgery and possibly nursing home care. Knowing my brother the way I did, I know he never would have wanted that. I know he would not have wanted to be a burden on me, my parents, or the healthcare system. It was a wrenching decision, but one I do not regret. My only regret was that because there had to be a forensic autopsy, we could not donate his organs.

    Life is precious. No one on earth holds that more true than a medic. We see its beginning (I've caught four babies in the back of the ambulance, three more made it out before I arrived), we see its ending (I've performed CPR more times than I can count ... three lived, one left the hospital whole and alive). We see nearly everything in between, including the most wondrous of miracles and the most horrendous of tragedies. (Don't ever ask a medic, "What is the worst thing you have ever seen?" Just don't ... trust me) And we also have a deep respect for death, recognizing that sometimes, its coming is a blessed relief and no man or woman should attempt to stand in its way, and any attempt to delay its arrival only prolongs the suffering.

    I cannot fathom a rule, regulation or policy that would deny healthcare to anyone, or prioritize based on age or likelihood of recovery. But at the same time, I cannot justify using up our healthcare resources which are already strained, to give treatments to those who really, honestly do not need them whether due to advanced age or terminal illness. I would rather make the effort to keep them comfortable as possible in the time they have left. I could never begin to answer the question of where should the line be drawn, nor would I want to. But I do believe that something needs to change.

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