The tragedy of my posts

List prices are high as the insurance companies often write in their contracts that any service provided will be reimbursed at an X rate, but if the provider ofters lower rates (to cash paying cutomers) then the insurance company can unilaterally lower the insrance reimbursement to the lowest rate.

This contract language is standard and not negotiable with the major health plans such as blue cross, Aetna, Cigna, etc…

also it helps to be see how office charges are determined:

patients equate fees fas being high but they disregard that most practices require 3-4 Full time employees per physician…and much of that work is directed towards dealing with the beuracracy associated with health insurance companies. Typically, it costs 34,000/year per employee so a physician can easily expect to pay 110-140,000 per year in employee costs. Add on malpractice at 15,000-70,000 annual costs, add on mandatory annul licensce fees and educational costs, then add on OSHA and materials costs, etc….there is easily $ 180,000-300,000 costs of operating a practice per year.

If you assume there are 70 patient office visits/week and 45 week/ year ….. thats about 3,ooo visits per year. assuming a cost of 200,000 /year … each visit fee must carry a minimal fee of $65.00 /visit to just pay for costs. Obviously when physician provide care for medicaid patients we are lucky to see reimbursement for $ 30.00/visit and medicare pays just about 78.00/visit on average. So then you see physicans forced to raise fees to compensate for the under reminbursed medicaid patients and the cost cover reimbursement of medicare.

Thus the incentives come in to either raise office fees or see more than 70 patients/week … or as above commentators point out…join the VA system or do something else than office based practice

Today I saw a patient who is homeless. He has severe aortic regurgitation and was admitted with heart failure. His echo showed an EF of 22%. I am a hospitalist and am on salary. What I needed was a cardiologist to see and cath the patient. The patient had the expectation that everything would be done without question. Because the cardiologist was such a nice guy, he came and cathed the patient. Normal cors. Then we call the CT surgeon who comes by and sees the patient. He recommends surgery next week at a different hospital. Since he is 58, the social worker is scrambling to apply for medicaid (without his help) so a small portion of his heart surgery can be paid for. After all of this (free) work by the cardiologist and CT surgeon he says, “How am I going to get to the hospital”. We go back and have the social worker give him a bus pass which he crumbles up in front of her and throws away.

This is a severe (but true) case. This person expects these highly trained physicians to see him for free without question. Another way to look at the tragedy of the commons is to ask how much free (or grossly inefficient) work physician do each day because it is expected? What other profession does this?

To rectify her complaint, medical care is overused by both her and her physicians because she does not know which costs to rein in and her physician don’t have an incentive to rein in costs. She does not
have the knowledge to realize what test is important and what isn’t. Additionally, even if she knew, most insurance plans make you pay a portion of the cost. So while I may not want a head CT for my headache if it cost $200, I may want it if it costs me $20. (especially if I’m frustated by my high insurance payment and want to “stick it to the man”).

I agree we are all guilty of shifting costs and as long as perverse financial incentives exist, people will do what is in their best interest.

To the last poster, I can only suggest an alternative. I think doctors ought to be able to selectively choose which procedures and services they will offer at Medicare and insurance rates and which ones they will not. At present, this is not possible; it is all or nothing. If I would be required to charge no more than 120% of Medicare for any given service, even that is nothing more than legislated price fixing. Nothing assures me that that is a sufficient rate for any particular service. And as with any price fixing, all that results in the end is a damper to supply, and in its worst consequences, black markets.

One added note ,the above commetor states:

“With respect to the comments posted by the doctors above, I think there are three separate issues here which are: (1) finding a way to cover the uninsured, (2) the adequacy of reimbursements from Medicare, Medicaid, and private insurers, and (3) the financial treatment of self-pay patients”

from a health policy perspective these items are separate….. but this is what physicians , in fact, treat every day. We have a mix between insured, underinsured and self pay patients….so yes, indeed, I might have a self pay patient who comes in for a limited problem and does not like the fact that a 10-15 minute encounter costs $ 130.00 dollars.

If the day comes that I might get have a population of patients that reimburse 120% of medicare…my fees would drop substantially…(and i actually would consider opening up a private practice again)

n my small opinion, the problem with health care costs are multifactorial and will not work unless ALL the factors in the equation are addressed.

There are two somewhat comparable single payer systems that can be studied. Canada and the U.K. Certainly the MAJOR complaints of these two taxpayer backed systems are inadequate funding. These complaints are both from the citizenry and provides.

The British Health Service operates within budget restraints that 10′s of millions of American’s would oppose. American’s don’t like restraints on care and the BHS is very strict on what types of care will be paid for. Limits ARE the rule.

The multiple problems with the current U.S. System are enormous…

1. Bureaucratic paper pushers probably take 25% of money that should be on health care. Just look at any hospital or private office, the numbers of people hired just to manage the paper work is staggering.

2. Costly testing ….although malpractice lawyers ridicule the idea, medical providers spend enormous resources on ordering tests and documenting things that will prevent lawsuits years later.

3. Over indulgence…its a fair estimate that 40% of our health problems are caused by self abusive behavior (smoking, drugs from alcohol to meth to cocaine, food intake..causing diabetes, coronary, and a whole slew of preventable problems, reckless drivers who eat big macs and talking on a cell phone, drunk drivers),
The list is vast…..

We cannot afford to be gluttons anymore.

4. Unrealistic expectations….we spend more on health care in the last 6 months of life than we do for the first 70 years.

4 a. Victims of our own success…people are living now long enough to survive their second or third cancer, 5 or 6th stroke, 8th year of advanced Alzheimers..with feeding tube in place yet cannot recognize anyone….
Complex medical procedures and drugs that do indeed keep alive but not healthy enough to be free of long term intensive medical care.

5. Declining resources….America’s ability to pay for care is now waning. No longer are we the world’s source of productivity..Our budget deficit and trade deficit have erodes our ability to pay our bills. Walmart is now the paradigm of success, while manufacturing is going to China. Walmart provides minimum wage salary and limited health care benefits, a far cry just from 25 years ago when good paying manufacturing jobs were abundant. Today CNN had a special on the shrinking of middle class America.

6. Increased costs…college and graduate tuition rises are far higher than inflation for the past 20 years… by the time a physician gets ready to practice they have put in 8 years of additional education post high school enormous debt load to pay off.
States are unwilling to fund more state supported med school slots.

etc…

so i think a single payor system alone as a fix is analogous to launching a manned space mission to the moon, bringing enough fuel ….but forgetting to bring all the other critical gear needed for survival.

mdopinion has made a critical point. There is no silver bullet to this problem and no one solution. We will need to see changes in a number of behaviors along with the entrenched financial interest. The problem of the commons shows the economic truth, that people will destroy an asset in an attempt to maximize their return.

Doctors are going to need to move outside their own interest to supply solutions that will ultimately benefit the population as a whole. Student debt load is staggering even for an undergraduate. Education has become a business, and like medicine, this has lead to some undesirable consequences. We need people with graduate level eductions in any number of fields.

We are a glutinous society. The medical industry is going to need to start at the edges in reducing cost by reducing use of scarce resources. This will be difficult given the financial interest of many service providers. I have personally watched terminally ill friends fight with doctors to limit medication to pain only, while the doctor talks about how they are wasting money. i.e. the doctor is loosing income. Pharma will consume as much of our resources as it is allowed to the point of bankrupting the country.

The list goes on. Like the old proverb: How do you eat an elephant? One bite at a time! This problem needs to be addressed with taking steps that can show immediate results allowing the larger issues time to be solved.

Steve Lucas

Chumperz is arguing for NP’s to provide cheapper care. Go ahead and see one, in most states they are lisenced to practice.

All you really need to do is look one up in your phone book.

The problem you will find is that the number of Nurse Practictioners seeking to do primary care is only a fraction of the numbers that are seeking to provide care in a subspecialty practice. You can call any major metroploitan area and find that for every NP doing primary care, 10 are working in subspecialty venues.

So you might as well demonize them as well.

This problem is incredibly complex. Yet at one level, the basic problem is quite simple, and it requires answering one question.

What is the purpose of the health care industry?

If you think the purpose of the health care industry is to function as a marketplace to assure profits for companies that are in the marketplace and to fund innovation in health care with profit as a primary motive, then you should be happy with what we currently have.

If you believe that the purpose of the health care industry is to create health in the public, then you should be dissatisfied with what we have.

Any problem that exists in the system is about how to balance profits and incentives; what behaviors to reward, and what things to punish.

Not having a job is rewarded; having a job with no benefits is not. As far as health care is concerned, being a veteran of the military or a prisoner is rewarded; being a veteran of the peace corps or being a single parent is not.

Opening a health insurance company and driving down the amount of benefit claims you pay out, and delaying the ones you pay out is rewarded; opening a private office and trying to reward your staff properly, treat patients fairly, and make the same amount of money you made last year is not.

Being an interventional radiologist is rewarded; being a primary care provider is not. Doing lots of cosmetic procedures which you can bill patients directly for is rewarded; doing “real medicine” which takes time and effort is not.

I had an economics professor once who told me to always look at what was rewarded in a system, because that was what you were going to get more of, and that’s what we have.

any of the above comments reveal immense ignorance about medical care and costs to provide that care.

Immediately above someone describes rationing as having to wait for a colonoscopy ( a family member has had an episode of diverticulits.) It is proper and wise to wait 2-4 months after an episode of diverticulits before proceeding to colonoscopy. A rush to place a 80 cm scope into a colon soon after having diverticulitis is risking tearing a hole into the colon wall, which almost always requires emergent surgical removal of a large portion of the affected region of the colon and very commonly leads to a colostomy ( a formation of a large hole in th abdomial wall where feces must be excreted) One should not mistake a delay of a few months to have a colonoscopy as a “rationing of health care”.
It is more likely a rational approach to provide sound and prudent health care.

another person desribes a health system in simple terms of supply versus demand.

Mundane medical related issues such as sore throats and indigestion very well could be handled at WalMart by a mid level provider. The lion’s share of health care cost is not assocated with these trivial issues. Life threatening issues such as cancer, stroke, Heart attack , respiratory failure, septic shock, renal failure and so on….require extreme care and providers who have extensive knowledge on how to provide remedies.

You will will ever find a Nurse practitoner willing to render care to people who are seriously ill. Someone above used a silly example of consumers having options when they wan’t to buy a car. (in a prior post a week ago) The analogy is made that health care should be as freemarket as a consumer picking and choosing a car based on cost.

You will never find someone who has renal or lung cancer or congestive heart failure or myocardial infarction taking the time to shop for the cheapest deal. The analogy is closer to a traveler who MUST travel to a distant city and must travel within one week or sooner. It is doubtful the consumer will find a cheap airline ticket with such short notice. I doubt any circumstance will arise where you have thousands of airplanes or highly trained professionals doing nothing except waiting to offer a cheap service. No one would expend the 8-14 years of training beyond 12th grade with the expectation that theywill provide service at the lowest cost. Walmart is fine for purchases of disposable goods, but I doubt Walmart will welcome a patron in a stretcher ,vomiting blood and asking for help now.

And again someone insists that they are not a charity case!!! I doubt that person ever did anything in their life that contributed in any meaningful way to the development and betterment of this world.

We all are charity cases….by fault of not having sacrificed ourselves to save anyone else, by fault of not having formed a nation from raw wilderness, by fault of being a human being!!! Anyone who does not think they are a charity case is woefully misguided. We all are charity cases and all will die soon enough. The only question is did we leave this world better than we left it.