Comments on: Some initial thoughts on healthcare reform

By: Ted

Ted — Thu, 19 May 2005 00:37:49 +0000

JB has a very clear picture about what the lower tier of his two-tiered system might look like. Sounds to me like a prescription for opening yet another front in the war on the poor (talk about open wards and color TVs is the same old coded language we used to hear about Welfare Queens). What we need is a system that restores the doctor-patient relationship, improves care, and is available to everyone. If the only aim is to shut up those who the current system, then we will make no progress with cockamamy schemes like the one proposed here. Our healthcare system is uncivilized, but not because we are unrealistic about its costs. (One need only to take a glance at what a handful of health insurance executives are being paid to deny coverage to those who already are paying more than they should for second-rate coverage to see what is truly wrong.) As a society, too, we always seem to find the money when we want to fight another war. Why is it that we have such a difficult time envisioning ourselves as a society that is willing and able to care for ourselves in a way that all of us would find commendable? Yes, I’m in favor of allowing anyone who wants to buy more to do so, but why set the bar for basic care so low?

By: Greg Pittman

Greg Pittman — Fri, 13 May 2005 20:30:41 +0000

There is no reason to lament the situation of the doctor fired for not seeing enough patients. It should represent, one way or another, I good experience. If the doctor’s in that practice “needed” to see 60 patients a day, then chances are their overhead was at that level, and too expensive for him. It’s also likely that their system did not account for a doctor with a lower volume having a lower percentage of the overhead (overhead probably distributed evenly). Some overhead works that way, but some is according to the volume of work you do.

On the other hand, the lamentable doctor no doubt needs a lesson in the practicalities of the business of medicine, by being more in touch with the costs of running a practice, and that if you “can only see” 15-20 patients a day, you will only be paid for that many.

By: Ron Greiner

Ron Greiner — Tue, 10 May 2005 15:19:19 +0000

The centerpiece of President Bush’s health care reform is Health Savings Accounts (HSA). A 30 year-old-couple and two children can get HSA insurance for $150 a month in Lansing, Michigan. Yet tax payers are paying over $1,000 a month for state employees and over $1,500 a month for Oakland County teachers.

I would think discussing health care reform would include how much consumers can save with the low cost HSA option favored by the President.

President Bush just went tax free with an HSA and he said, “Hopefully, when I’m an old guy my HSA will be bulging with money.”

By: jb

jb — Mon, 09 May 2005 01:45:48 +0000

Clearly we cannot afford to continue to give everything to everybody from a medical perspective. My proposal: a 2-tiered system. The basic care would be provided free by the government. Any US citizen could walk into the USCare clinic (possibly pay a nominal fee of $3-5) and get basic care. That includes evaluation, prescriptions (generic only), basic surgery (no hip replacements). Advanced imaging (CT,MRI,PET) strictly limited or not at all. If you have surgery, you will be cared for in an old-fashioned open ward post-op unit, where an RN could directly observe 15-20 patients and supervise a few LPN and techs. No color TV, phone, and private room for USCare patients. Anything else has to be obtained in the private system, where you can pay cash or use your private insurance.

USCare would be financed by dismantling the current government payments for health care. Medicaid and Medicare will be phased out over a decade or so to limit the number of people who paid into Medicare but will not get the benefits. USCare will cost much less, not only because services are limited, but because there will be no lawsuits, and therefore no defensive medicine. No documentation expenses aside from the super-efficient EMR that will give nationwide access to any doc or nurse who is caring for the patient. Docs will happily accept low reimbursement for USCare work because they will be free to practice the way they always wanted. No need to order CYA tests, no need to document 12 bullets to get paid, no fear of career ending lawsuits.

Some might complain that offering less than state of the art care to people is unethical or immoral. Remember that this is not bad care, in fact, it was the care that the high and mighty received 10-20 years ago. Today’s blockbuster Rx is tomorrow’s OTC generic pill (Remember when Tagamet and Motrin were Rx blockbusters?). Those who are still unhappy may contribute to the charity that will be established to provide Lipitor and hip replacements to the indigent. Care will also be advanced because all patients will be enrolled in any clinical trials relevant to their diseases.
This will have benefits for the private medical world also. There will be no cost shifting, so services will be billed to Blue Cross and self-payers for what they cost to provide. Blue Cross will soon learn that the 12 bullet CPT system only raises everyone’s costs, and will be eliminated. The true cost of the current tort system will be apparent, and fixes will be implemented.
The biggest advantage: it will finally shut up those who think that the US is uncivilized for expecting people to pay for their health care. It will also be an ongoing experiment that will challenge high cost interventions to prove themselves. The inevitable huge bureaucracy that will be required to run USCare should not be any worse than the ones we now have to run Medicare and Medicaid.

By: DrTony

DrTony — Sun, 08 May 2005 01:41:10 +0000

Good post. See my comments here.

By: amy

amy — Sat, 07 May 2005 03:51:49 +0000

A, but you don’t consider the overhead. The doctor spends about 55-60% on overhead. It’s not going to cost more, since the overhead will drop and the doctor will do more (even billing, for example, or answering phone messages in person, or using e-mail, internet for scheduling appointments). Also, the office space you need is smaller, why would you need 3 exam rooms if you have enough time to clean the previous one. So, you will need smaller space. Also, you will write better prescriptions, will have time to check if a medication is too expensive for your patient, for example. You will order less tests, because you will be less insecure about your patient’s problems and physical exam. I’ll give you an example : if you have to “squeeze’ a patient in 10 min. and he needs wax removal, you may just want to refer him to ENT because removing wax can be time consuming. Same thing may happen with a pelvic exam- why bother, when you can order a STAT ultrasound. I know it sounds like lousy medicine (it IS lousy medicine) but if all your scheduler gives you for a patient are 10 min, what do you do ?
It’s more complicated than a second grade math problem.

By: Bob Rauner,MD

Bob Rauner,MD — Sat, 07 May 2005 02:51:08 +0000

Actually, income doesn’t just relate to patient volume. It is also directly related to overhead. The main problem in primary care is that our overhead is rising 2 or 3 times faster than our reimbursement. (And if Medicare’s “sustainable growth rate” calculations are enforced, our reimbursement will start decreasing 3-5% per year.) The only solution is for us is to see more patients. Our increased overhead comes from increased regulation (HIPPAA, OSHA, licensing, etc.), increased legal costs (malpractice), and increasing documentation costs (required by Medicare, Medicaid, Insurance companies, lawyers, etc.). I would claim that we are the most regulated/overseen industry on the planet. It is no longer possible for a primary care doc to just hire a receptionist and a nurse and start up a business. If I were able to see 12-15 patients a day with only 2 employees I could make a great living. The problem is that this can’t be done anymore. Each doc also needs 1-2 billing people to stay on top of trying to collect from weasling insurance companies, 1 person to do transcription & medical records, and now a computer support system as many are starting to require billings to be submitted electronically and we have to maintain secure office networks. Our income wouldn’t drop (and might even be higher) if we only had to employ a nurse and a receptionist.

By: Harvey

Harvey — Fri, 06 May 2005 17:31:45 +0000

It seems that the central question is how much money doctors expect to make.

How is a doctor who sees 15 patients per day giving good care to be able to make as much as the one seeing 60 patients and giving poor care?

If all doctors now seeing 60 patients were to switch to seeing 15 patients, we’d need 4 times as many doctors, and if each is to make the same amount of money as before, the costs of medical care will necessarily quadruple.

The only ways around that are either for fewer patient visits, or for doctors’ income to drop. Is the former acceptable to patients? Is the latter acceptable to the medical profession?