From the DUH files:

[Warpy]

Seniors wait on care, grow sicker as copays rise

LOS ANGELES - Higher Medicare copays, sometimes just a few dollars more, led to fewer doctors visits and to more and longer hospital stays, a large new study reveals.

With health care costs skyrocketing, many public and private insurers have required patients to pay more out-of-pocket when they seek care. The new study confirms what many policymakers had feared: cost-shifting moves can backfire.

"Patients may defer needed care and may wind up with a serious health event that might put them in the hospital. That's not good for the patients, not good for society, not good for anybody," said Dr. Tim Carey, who heads the University of North Carolina's Sheps Center for Health Services Research.

http://www.msnbc.msn.com/id/35107033/ns/health-health_care/

(gee, ya THINK?)

[Jim__]

1. Our "health care system" is ass backwards. - n/t

[Warpy]

2. Yes, it seeks to contain costs by punishing people who need services

as though they can control when they're sick or how sick they get. This is utterly ridiculous.

Health or the lack of it is not a consumer decision. It's time for the bloodless bean counters to realize that sad fact and act accordingly.

[busymom]

3. And reduced reimbusement to hospitals and doctors that

started Jan 1 means that in many cases it actually costs money to see a patient. This means that hospitals and clinics are already planning for the 30% reduction that was ushered in by the CMS changing billing for consultations as well as cuts to what it will pay for radiology services etc. This means clinic closings/inpatient psych closings and the closing of other facilities that tend to run in the red but are boosted by payments. Bye bye PET scanner your facility was hoping to get ... and your doctor is making 30% less too. I wonder if he feels less motivated to squeeze in that one last patient after a 10 hour day or if he'll just go home to his family and see you tomorrow.

Medicare pays ass-nothing as it is.

These changes will slowly bring in a new era of medicine and I imagine it won't be pretty. It seems like everyone here likes to blame those mean ole' nasty doctors for earning above the average after going into $150,000 in debt + and then investing 8 years of college and 3-9 years of residency and fellowship training where they earn less than minimum wage for hours worked...but we celebrate the carpenters, plumbers and home inspectors that make wise choices, set their businesses up to be profitable and then in some cases earn more than your doctor ... who works all hours of the night/day in many cases.

Blame in on the doctors though....but....paying pennies on the dollar for medicare will reduce access to services, will result in clinic and hospitals closing their doors, will increase waiting times, will limit the number of jobs for nurses and other hospital employees and in general is not a good thing for anyone.

Keeping a hospital running costs money. Facilities need electricity (and a lot of it), expensive equipment, nurses, doctors, techs, MA's, PA's, NPs, housekeeping, cafeteria staff...you name it. The hospital here has frozen all hiring, physician salaries are going down by as much as 30% (and fyi, I drive a 2001 van that has been paid off for years, is full of dings and scratches and that I will drive until the wheels fall off...definitely not the BMW some people imagine) and they are getting rid of 1:1 nursing in the clinics now. They will be closing the free outreach clinic at the end of the year, are talking about having to close inpatient psych (our unit is the largest in the state because due to cuts already, many of the major facilities already reduced theirs to next-to-nothing) and possibly 1 of the smaller hospitals that is an hour away. All of those people will have to come here for care now if that happens.

Did I say that healthcare costs money? Would you go to Target, pick out a product and then demand that you get it for pennies...or even...that Target pay you to buy it?

Something that is lost in this discussion is getting rid of physician student loan debt, low residency payment and reducing our litigious nature to cut costs. If your doctor didn't have to carry an outrageous malpractice policy that was more than she could earn each year, she might still be practicing in your state...and you wouldn't have to cross state lines to deliver a baby if you were unlucky.

Unpopular opinion here...I know.

[hedgehog]

4. You touch on several issues here:

1. Hospital costs: I'd like to see a good accounting of actual hospital costs. Where does the proverbial $1 Tylenol tablet come from? Why does it cost $20 at a doctor's office, $100 at an Urgent care clinic and $500 at an ER to get 3 stitches, especially when sometimes everyone involved is working for the same Health company and in the same building?

2. Education costs: My doctor has 2 children; the one with a doctorate in Physics is graduating with some savings in the bank. The one going for medicine is still years from actually practicing and already has so much debt she is going to have to specialize in order to have any chance of paying down her debt. Which brings us to

3. Doctor's salaries: why do the front line doctors who keep us healthy, the family doctors, internists, pediatricians, get paid so much less than specialists? Why do specialists get paid so much? How do we balance payments for my doctor here in Upstate Central new York compared to another doctor practicing in Brooklyn?

4. Malpractice suits are a terrible way to address medical error. All too often, the insurance companies pay out regardless of whether the doctor is at fault or not. Bad doctors keep right on doing bad medicine. Good doctors find themselves second guessing every decision. We need to set up some no fault systems like the vaccine court for situations that no doctor can predict or prevent, such as a child born with a life long disability who will need ongoing care. We also need to research and implement systems to prevent human error.

5. We need to reassess our medical system top to bottom. For example, what is the function of a hospital? Can we perform that function better say with free standing maternity clinics, surgical units, chronic disease centers, etc? How can we better use doctors and nurses? I'll tell you one thing; having doctors and nurses spend hours on the phone arguing with an insurance company clerk is a waste of their time and training.

[Warpy]

5. I can answer a few of these

1. That $1.00 Tylenol comes from the doctor who writes the order, the nurse and pharmacist who transcribe the order, the pharmacist who checks for drug interactions and allergies, the nurse who does the same, the nurse who brings it to you and the nurse who both watches to make sure it worked without bad side effects and documented everything. It's not just a Tylenol if you're medically fragile enough to be in hospital.

The different costs for the same services in the same building reflect the different costs for keeping those areas open. A doc's office is cheap. An ER is terribly expensive.

2. The cost of physician education is nothing short of ridiculous. It should be a 6 year program: 2 years for English and hard sciences followed by 4 years of med school. No doc should have to graduate with the burden of debt present docs have. It completely changes how they practice medicine and it isn't good for any of us.

3. Specialists have to undergo additional education and training. The increased salaries they are paid reflect that. GPs are never going to make more than specialists. However, docs who go into general medicine really need to have something done about their ridiculous debt loads.

4. You've got that right. 5% of the doctors are responsible for 50% of the payouts, year after year. You'd think insurance companies would cut their losses and cancel their policies, but they don't. Something else is going on there.

5. You bet your ass we do. Too many expensive items are duplicated unnecessarily within the same market, driving costs up. Just getting rid of Byzantine paperwork from competing insurance plans will cut a great deal of unnecessary cost.

[busymom]

6. Regarding specialist salaries...

Specialists also dedicate themselves to longer periods of training and many times require more time to evaluate a patient's chart, do a physical exam, order more extensive testing and then come up with the right diagnosis. You are paying for their extra time, effort and expertise. It is the reason also that a real plumber earns more than your local handyman down the block who isn't really a plumber but can fix it anyway (or at least try...ultimately usually resulting in also having to pay a real plumber later!)

Don't worry though. Now the CMS has come in and made is so that specialists can no longer bill consults codes or appropriately for their services, effectively bringing their salaries down to that of generalists and removing every last shred of desire to step up to the plate and add more years of training.

In a few years you won't have to worry about it. Getting in to see the "doctor" won't be a possibility. Nurse practitioner and PA...sure...but doctor? Not unless you are private pay.

[hedgehog]

7. Some comments:

1. Just what is it about the ER that makes it so terribly expensive? How does the ER compare to Urgent Care? Is the cost of running the ER really that high, or are the people who have insurance paying the bills for people who can't? Is the Er possibly a dumping ground for hospital overhead costs? Could one of those costs be high salaries for the hospital CFO and CEO?

2. The requirement for a four year degree to enter medical school came about to ensure a basic grounding in chemistry , biology and physics. I think solid high school work in these areas probably covers more ground than a university course from 30 years ago. The 6 year program makes sense to me.

3. My family doctor did get advanced training in his specialty. He is responsible for keeping people healthy, identifying and treating chronic diseases and for diagnosing problems that need to be referred to a specialist.

[busymom]

8. Well

I can't speak to the expense of the ER.

Of course your family practitioner did extra training after medical school. He had to get through a 3 year FP residency. An Infectious disease specialist (for example) does 3 years of internal medicine and then an ADDITIONAL 3 of ID fellowship training.

My best friends husband is a pediatric surgeon. He did 8 years of college, 7 years of general surgery (to include research so that he could be competitive) and another 2 years of pediactric surgery fellowship.

There was never a time that he worked less than 100 hours/week for the honor.

Think about that.

How should he be compensated?

[iverglas]

9. on # 5

having doctors and nurses spend hours on the phone arguing with an insurance company clerk is a waste of their time and training.

I post this from time to time, but here it is again in case someone hasn't seen it -- it is outdated now, but I can't see the situation having changed other than for the wrose from the US perspective.


http://www.pnhp.org/publications/nejmadmin.pdf (2003)

Costs of Health Care Administration in the United States and Canada

abstract

background
A decade ago, the administrative costs of health care in the United States greatly exceeded those in Canada. We investigated whether the ascendancy of computerization, managed care, and the adoption of more businesslike approaches to health care have decreased administrative costs.

... results
In 1999, health administration costs totaled at least $294.3 billion in the United States, or $1,059 per capita, as compared with $307 per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada’s national health insurance program had overhead of 1.3 percent; the overhead among Canada’s private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers’ administrative costs were far lower in Canada.

Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations’ figures exclude insurance-industry personnel.)

conclusions
The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.

Doctors in Canada don't spend any time arguing with insurers.

(edit - you can pretty much ignore the part about Canada's private insurers in the above -- they cover only non-medically necessary services; private supplemental insurance might pay for Lasik, or vasectomy reversal, in addition to services outside direct medical services, e.g. dentist, optometrist.)

They have a handy computer program that contains all the codes for all covered services and the amount paid by the public plan for each, into which they input what they do, and which spits out the billing to the plan. Ditto, I assume, for other private providers (x-ray/ultrasound labs, blood labs, physiotherapists, etc.)

Hospitals don't bill anybody, as far as I know. They are publicly operated (all but a tiny handful of grandparented technically private institutions that operate essentially the same as the others), by non-profit foundations, and they are funded globally, not on a fee-for-service basis.

Just imagine everything that doesn't cost!

[HuckleB]

10. Kick.