The Sad Case of the Patient Protection and Affordable Care Act

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Let me try

First - fix the tort laws that allow / permit big dollar suits for an unexpected outcome. Negligence should be punished, but sometimes medical folks do their best, and the outcome is not what the patient wanted.
Second -- get more GP's - particularly in medically underserved areas. If that means paying off the loans over X years while the doc / nurse is out in the fields, great.
Third -- Expand the walk-in clinics & urgent care facilities. These are the first line of triage. Save the ER's for the bad stuff.
Fourth -- I like the idea of co-insurance. You pay 20% of your visit for doctor / dentist / clinic / urgent care / ER's without an admission. Hospitals are a flat fee / day.
Fifth -- Open seasons -- Pick a month and you have those 30 days to get insurance. If you sign up during the open season, pre existing conditions are covered. Otherwise, no and you have to pay 75% of the docs' bills for 6 months for treatment of the condition instead of the 20%.
Sixth -- encourage group practices with multiple specialties. You may have pediatricians, GP's, X-Rays, Labs in one place. If you need a specialist, you get one affiliated with your hospital (20% co-insurance).
Seventh - limit your annual payout to ????????. Don't know if it should be a % of taxable income, or a flat amount for individuals or families.

Discussion -- should doctors be on salary or a cut / patient? Also, for the poor who can't afford something, there will be something, but what it will be, I have no idea.

Think of this as a starting point. And I keep saying that I like France's system.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

The only way to get people to be accountable is to remove the safety nets. Plain and simple. I realise that Hippocrates has directed otherwise, but there needs to be a line drawn somewhere. Come up with a lien system if necessary.

Theoretically this is great. Pragmatically this is not going to happen. There are people who want to forbid abortion and but enough that don't agree that it isn't law. You aren't going to find too many people who would be OK with a law that lets people die who can look them in the face even if the medical establishment bought in.

What realistic plan can you come up with? They do not let people die because they can't pay. What do you do to the people who have nothing? You remove the safety nets and that just gets you a ton of people who come in with multiple co-morbidities in a medical mess that costs us more.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

OK- now propose something realistic that gets people to be held accountable. Most people think they should be held accountable but no one has come up with a way to make a consequence that doesn't screw the person who is taking care of them.

The gov't isn't the issue. Every time they try to set limits someone comes along and screams bloody murder that they aren't being served like it was Burger King instead of medicine or the flip side, that the insurance companies should have no regs and shouldn't be held accountable because the market fixes everything.

The only way to get people to be accountable is to remove the safety nets. Plain and simple. I realise that Hippocrates has directed otherwise, but there needs to be a line drawn somewhere. Come up with a lien system if necessary.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Sounds like a novel idea! I know this is something I've been professing for quite a while, the fact that there's no such thing as a free lunch. You need to make your own good choices and be held accountable for your own actions. The large government fascists are glorified over-controlling parents.

OK- now propose something realistic that gets people to be held accountable. Most people think they should be held accountable but no one has come up with a way to make a consequence that doesn't screw the person who is taking care of them.

The gov't isn't the issue. Every time they try to set limits someone comes along and screams bloody murder that they aren't being served like it was Burger King instead of medicine or the flip side, that the insurance companies should have no regs and shouldn't be held accountable because the market fixes everything.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Back at you. You are singing my song. When I started in practice it was a calling. As an NP I make way less money than if I stayed on the floor (I make about 1/3 of what I could've if I stayed in house as a floor nurse). Until very recently the satisfaction of making a difference was more than enough to compensate for the $ and time. Now the needs way outweigh what I can do to help.

Things have changed on both sides of the table.

Even without all the insurance changes most of the 'Providers', nurses and medical staff we have coming out now want to have a job that is like a McDonald's shift. They don't want to take call, are proud they know how to set limits and will tell you they don't 'own it' (sadly they don't connect 'it' with a person, only the inconvienience), they want to work certain hours and they think like cookie cutters because they document in a system that discourages anything that doesn't fit into a little bubble in the computer window.

It seems people who feel they are owed care way outnumber those who are grateful when you go the extra mile. Before we would see people who gave us vegetables and had a pre-arranged payment plan. Now we go out of our way to work something out, people sign the plan and it means nothing. They say "I am sick, you have to see me, I don't care if I owe 800$. You can't deny me care!! I will report you" (Sadly we hear this a lot lately)

dxmmkd316 posted about waiting to get an appt until they knew they needed it. I wish more people thought like that. People seem to have lost the skill for self care and commonsense to take care of themselves or family members. It is like a massive dumbing down. Not much critical thinking. I am continually baffled and astonishing that people who are in financial duress are insistant they need an appt spending 25-50$ to see me if they vomit once or have a sniffle. They think if they come we have some sort of magic even when we try to tell them coming in will net them the same advice we will give over the phone. Many of these people come in for the exact same complaint and get teh exact same advice over and over. My MA keeps telling me to suck it up and collect the copay but I think it is a huge waste of resources and $.

Sounds like a novel idea! I know this is something I've been professing for quite a while, the fact that there's no such thing as a free lunch. You need to make your own good choices and be held accountable for your own actions. The large government fascists are glorified over-controlling parents.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Keep it coming Les-I think I love you. I may not have the exact same list but we are sure darn close. Jenny and I loved what we did-we hated Sundays because we had to wait a day to be back in the office. It was like living a dream. I was able to do what was best for every patient. We did not practice in an affluent area-it is strictly blue collar around here. But NO ONE went without care. If things continue as they are going now-we will continue to lose quality medical people. Physicians and Nurses who care and are qualified will be leaving the profession-only to be replaced by providers (hate that generic term)who simply follow a cookbook fo recipes that the government and insurers issue.

Back at you. You are singing my song. When I started in practice it was a calling. As an NP I make way less money than if I stayed on the floor (I make about 1/3 of what I could've if I stayed in house as a floor nurse). Until very recently the satisfaction of making a difference was more than enough to compensate for the $ and time. Now the needs way outweigh what I can do to help.

Things have changed on both sides of the table.

Even without all the insurance changes most of the 'Providers', nurses and medical staff we have coming out now want to have a job that is like a McDonald's shift. They don't want to take call, are proud they know how to set limits and will tell you they don't 'own it' (sadly they don't connect 'it' with a person, only the inconvienience), they want to work certain hours and they think like cookie cutters because they document in a system that discourages anything that doesn't fit into a little bubble in the computer window.

It seems people who feel they are owed care way outnumber those who are grateful when you go the extra mile. Before we would see people who gave us vegetables and had a pre-arranged payment plan. Now we go out of our way to work something out, people sign the plan and it means nothing. They say "I am sick, you have to see me, I don't care if I owe 800$. You can't deny me care!! I will report you" (Sadly we hear this a lot lately)

dxmmkd316 posted about waiting to get an appt until they knew they needed it. I wish more people thought like that. People seem to have lost the skill for self care and commonsense to take care of themselves or family members. It is like a massive dumbing down. Not much critical thinking. I am continually baffled and astonishing that people who are in financial duress are insistant they need an appt spending 25-50$ to see me if they vomit once or have a sniffle. They think if they come we have some sort of magic even when we try to tell them coming in will net them the same advice we will give over the phone. Many of these people come in for the exact same complaint and get teh exact same advice over and over. My MA keeps telling me to suck it up and collect the copay but I think it is a huge waste of resources and $.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Here's why I think copays are not the answer and coinsurance is. I didn't think twice about going to the doctor when I had a copay of $25. Now that I have coinsurance, where I pay a percentage of the cost for non-preventative care, I think twice. "Does this really require a doctor's visit?" is the first question that crosses my mind now.

Obviously there are trade-offs, premiums vs. co(pay/insurance), high/low deductibles, etc. But overall, I agree. Beyond preventative care (physicals, immunizations, etc.), there absolutely should be a per-visit shared cost.

Said very well and expresses exactly how I also feel. Call this token cost whatever-coinsurance, copay, doesn't matter. But it should be enough of a deterrent so that everyone has to think before they run to the ER for a cold or a sneeze. It can be nominal enough so that it is not a horrible burden for anyone. The issue of preventive care is separate-but briefly-preventive care should be defined as doing something that has been PROVEN to help prevent morbidity and mortality. If there is no evidence that something fits that criteria-I would not call it preventive care.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

We want to contain medical costs.
We think it is Ok for insurance companies to pay people who do not have advanced medical degrees to make decisions regarding what will be covered.
We are offended when it is suggested that a team of medical experts make general recommendations regarding care for certain diagnoses
We declare people sshould have personal freedoms to make decisions regarding medical care.
We complain that end of life care costs too much
We do not think it is OK for the patient to have an advance directive that says they should not get care or the family can decline further treatment
We have people who go to court to forbid withdrawal of life support systems for those outside their family
We want to ban assisted suicide.

Keep it coming Les-I think I love you. I may not have the exact same list but we are sure darn close. Jenny and I loved what we did-we hated Sundays because we had to wait a day to be back in the office. It was like living a dream. I was able to do what was best for every patient. We did not practice in an affluent area-it is strictly blue collar around here. But NO ONE went without care. If things continue as they are going now-we will continue to lose quality medical people. Physicians and Nurses who care and are qualified will be leaving the profession-only to be replaced by providers (hate that generic term)who simply follow a cookbook fo recipes that the government and insurers issue.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Agree again and agree with the co-pay thing.

One of our biggest problems is we are schizophrenic in what we want.
We don't want to pay for prevention.
We don't want to pay for people to have basic insurance.
We don't want to make people pay to get insurance if they don't want to.
We don't want to deny care to people who don't pay.
We don't want to take responsibility for the fallout when they cost the medical system huge cash.
We can't understand why people don't pay in when there is no consequence.
We don't allow consequence- you cannot ethically deny care.
We don't want to pay for people to prevent pregnancy.
We don't want to pay for the kid when it comes out.
We want to get medical care for little or no cost.
We want medicine to be a free market to regulate itself.
We want to decrease cost of care
We have an increasing population who will be sick.
We won't pay for home care
We will pay for nursing home treatment at huge cost.
We expect families to help out their relatives
Most families are now scattered.
We want the community to help but only voluntarily.
We want medicine to be cheaper
We don't want to impede the pharm companies from making profits for the investors.

As a society we are very unrealistic and if someone actually talks about how our expectations are schizoid it is political suicide. No one can propose a compromise because that would mean admitting we can't achieve everything we want and there is no absolutely right choice.

We want to contain medical costs.
We think it is Ok for insurance companies to pay people who do not have advanced medical degrees to make decisions regarding what will be covered.
We are offended when it is suggested that a team of medical experts make general recommendations regarding care for certain diagnoses
We declare people sshould have personal freedoms to make decisions regarding medical care.
We complain that end of life care costs too much
We do not think it is OK for the patient to have an advance directive that says they should not get care or the family can decline further treatment
We have people who go to court to forbid withdrawal of life support systems for those outside their family
We want to ban assisted suicide.

[dxmnkd316]

Re: The Sad Case of the Patient Protection and Affordable Care Act

This is an over simplification but here goes-I have always felt that so much abuse of the medical system could be eliminated by simply charging a token fee-let's say $2 every time someone used their coverage. Call it a copayment or whatever. I had patients that would ask for the moon in treatment-simply because (and they told me so) it cost them nothing. Often times asking by name for incredibly expensive drugs-when less expensive ones were perfectly adequate-simply because it cost them zero. Of course this does not address the myriad of other problems and abuses and inequalities. But I could not agree with you more-when people pay nothing for a service(medical or otherwise)-then they think it costs nothing. They do not know or do not care that it costs everyone.

Here's why I think copays are not the answer and coinsurance is. I didn't think twice about going to the doctor when I had a copay of $25. Now that I have coinsurance, where I pay a percentage of the cost for non-preventative care, I think twice. "Does this really require a doctor's visit?" is the first question that crosses my mind now.

Obviously there are trade-offs, premiums vs. co(pay/insurance), high/low deductibles, etc. But overall, I agree. Beyond preventative care (physicals, immunizations, etc.), there absolutely should be a per-visit shared cost.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Doc and Les

Very good points. Just as a reference, when I was a lad back in the 60's, Dad had Major Medical which covered the hospital. We paid for everything else. When I got my government job in 1979, Blue Cross / Blue shield covered more, but not as much as they do now (and for a heck of a lot less than what Feds are paying for BC/BS high option now).

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Agree again and agree with the co-pay thing.

One of our biggest problems is we are schizophrenic in what we want.
We don't want to pay for prevention.
We don't want to pay for people to have basic insurance.
We don't want to make people pay to get insurance if they don't want to.
We don't want to deny care to people who don't pay.
We don't want to take responsibility for the fallout when they cost the medical system huge cash.
We can't understand why people don't pay in when there is no consequence.
We don't allow consequence- you cannot ethically deny care.
We don't want to pay for people to prevent pregnancy.
We don't want to pay for the kid when it comes out.
We want to get medical care for little or no cost.
We want medicine to be a free market to regulate itself.
We want to decrease cost of care
We have an increasing population who will be sick.
We won't pay for home care
We will pay for nursing home treatment at huge cost.
We expect families to help out their relatives
Most families are now scattered.
We want the community to help but only voluntarily.
We want medicine to be cheaper
We don't want to impede the pharm companies from making profits for the investors.

As a society we are very unrealistic and if someone actually talks about how our expectations are schizoid it is political suicide. No one can propose a compromise because that would mean admitting we can't achieve everything we want and there is no absolutely right choice.

Virtually none of what you listed is ever reported on-and if it was-the public would just not understand or even care. We have produced a population that is all give me, take care of me, but don't charge me and don't make me pay for it. I am not exactly sure when medical care became a right and not a privilege. Medical care generates a lot of cost and of course a lot of income. But now everyone wants a piece of that medical pie. You have medical doctors, osteopathic doctors, nurse practitioners, physicians assistants, homeopathic practitioners, nutritionists, chiropractors, etc. And everyone wants to earn a living. Some treatments administered by all of these groups are based on some solid science or detailed clinical trials. Some are not. But so many are now covered by insurance or government payment-that costs are out of control. Decisions about medical care are increasingly being made by non medical personnel. In a previous post FreshFish highlighted a brief note about the AMA. What he posted is absolute truth. The AMA does not represent practicing physicians. Only about 15-20% of doctors belong and a great percentage of those that do are not the ones seeing patients and providing care. Many push paper around, review medical articles, and are not out in the medical world tending to patients. When i first entered practice most doctors belonged to the AMA. Now, I honestly do not know a single doctor who pays dues. But i see the AMA used politically as support all the time. If they wanted the truth, however, they should ask those of us who have actually been taking care of patients and especially those who have been doing it for a long time who have a perspective of how things have changed. Just my medical 2¢

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Thanks for the kind words. We do seem to agree pretty often. I guess we have had a lot of similar experiences in the health care industry. What i find particularly upsetting is using all sorts of statistics to compare US medical care with that of other countries. It is totally ludicrous-we have a distictly different population than these same countries. We have 310+ million people with a great percentage of immigrants. How can this be compared with a country like Canada who has a population 1/10th the size (and access to medical care across the border since 75% or more of their population lives within driving distance of the US). Or Australia which has a similarly small population and restrictive immigration policy. Life expectancy, neonatal mortality-these are often the stats used to compare-are also suspect since it is very difficult to compare, using those statistics, homogenous societies like Japan with unrestriced heterogenous populations more like a melting pot in the US. This may be hard to swallow for many-but the best way to decrease medical costs in this country is to stop rewarding the increase in population. Having less children, allowing less immigration, both politically untenable-would go a long way towards decreasing the amount of money needed to care for the population.

Agree again and agree with the co-pay thing.

One of our biggest problems is we are schizophrenic in what we want.
We don't want to pay for prevention.
We don't want to pay for people to have basic insurance.
We don't want to make people pay to get insurance if they don't want to.
We don't want to deny care to people who don't pay.
We don't want to take responsibility for the fallout when they cost the medical system huge cash.
We can't understand why people don't pay in when there is no consequence.
We don't allow consequence- you cannot ethically deny care.
We don't want to pay for people to prevent pregnancy.
We don't want to pay for the kid when it comes out.
We want to get medical care for little or no cost.
We want medicine to be a free market to regulate itself.
We want to decrease cost of care
We have an increasing population who will be sick.
We won't pay for home care
We will pay for nursing home treatment at huge cost.
We expect families to help out their relatives
Most families are now scattered.
We want the community to help but only voluntarily.
We want medicine to be cheaper
We don't want to impede the pharm companies from making profits for the investors.

As a society we are very unrealistic and if someone actually talks about how our expectations are schizoid it is political suicide. No one can propose a compromise because that would mean admitting we can't achieve everything we want and there is no absolutely right choice.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

DrDemento- awesome post! At some point people will realize it is about the money and not health care.

FF The gov't plans seem less serendipity than the private insurance. I know you want to connect the problems mu practice experiences with the gov't intrusions but I don't agree. I find it sig easier to deal with the gov't plans than the private insurances. I could tell stories all day about plans excluding things arbitrarily not because of evidence based medicine but because the HR dept of that company decided to exclude it (my favorite was excluding cardiac echograms but covering all other imaging). This was occuring way before the Bill went thru. I may be wrong but I think this is in direct response to the aging population. The burden on the system will go up by default. Even the most efficient system cannot decrease the number of patients who will have increasing med needs as they get older.

Yes there is fraud. Not sure what that has to do with anything. That applies to all insurances as far as I know.

Thanks for the kind words. We do seem to agree pretty often. I guess we have had a lot of similar experiences in the health care industry. What i find particularly upsetting is using all sorts of statistics to compare US medical care with that of other countries. It is totally ludicrous-we have a distictly different population than these same countries. We have 310+ million people with a great percentage of immigrants. How can this be compared with a country like Canada who has a population 1/10th the size (and access to medical care across the border since 75% or more of their population lives within driving distance of the US). Or Australia which has a similarly small population and restrictive immigration policy. Life expectancy, neonatal mortality-these are often the stats used to compare-are also suspect since it is very difficult to compare, using those statistics, homogenous societies like Japan with unrestriced heterogenous populations more like a melting pot in the US. This may be hard to swallow for many-but the best way to decrease medical costs in this country is to stop rewarding the increase in population. Having less children, allowing less immigration, both politically untenable-would go a long way towards decreasing the amount of money needed to care for the population.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Thanks very much for your perspective. It reflects the same feelings and attitudes my soon-to-be-former physician related, and the experiences of most of the medical professionals I deal with in my work. It seemed to me that Obamacare was more a vanity project than any kind of serious effort to address the problems we face.

I think it is also revealing that Mrs. Les' practice is in MA, the home of RomneyCare, and it appears many of her frustrations are more acute in MA than in other states.

As many others have pointed out, there is always rationing, and if you try to cap costs then some other form of rationing applies....PV=nRT, so to speak...or to put it colloquially, there is no free lunch.

For decades, the root of the problem has been that the person who receives the care doesn't see the bill. If someone else is paying for what I get, then inevitably there will be a misallocation of scarce resources.

I'd love to listen and learn over a tasty cold beverage sometime. There is a direct correlation over time between the number of government mandates and the cost pressure on insurance companies. My auto insurance company is tremendously responsive because they are allowed to set rates based on experience, and so because of price competition they have to give good service or you just go elsewhere. Many people I've talked to have the same experience with auto and home insurance: you have a claim, they pay it promptly, because it's all built into their pricing up front and there is no pressure to cut corners. If they had the same number of mandates and restrictions as health insurers, we'd talk about them the same way too.

This is an over simplification but here goes-I have always felt that so much abuse of the medical system could be eliminated by simply charging a token fee-let's say $2 every time someone used their coverage. Call it a copayment or whatever. I had patients that would ask for the moon in treatment-simply because (and they told me so) it cost them nothing. Often times asking by name for incredibly expensive drugs-when less expensive ones were perfectly adequate-simply because it cost them zero. Of course this does not address the myriad of other problems and abuses and inequalities. But I could not agree with you more-when people pay nothing for a service(medical or otherwise)-then they think it costs nothing. They do not know or do not care that it costs everyone.