The Sad Case of the Patient Protection and Affordable Care Act

[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).

[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.

[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.

[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.

[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.

[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 $.

[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

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

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

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.

[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.

[FreshFish]

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

Many thanks to Mrs. Les, Dr. D, and dxmnkd316 (and joecct now) for their thoughtful, passionate, articulate, heartfelt comments!

I "get to" read trade journals and am able to learn about various practice models and trade practices from different states around the country, and here are a few "best practices" from various parts of the country that we could expand upon and learn from:

> idea: put MDs on salary instead of compensate them based on fee for service: see Kaiser Permanente in CA for example. MDs and staff can concentrate totally on serving the patients properly and well.

> idea: involve patients in billing audits: some insurance companies ask patients to double-check their hospital bills and give them a financial incentive to report mistakes ("hey, I see a charge here for a medication I was never given"). It is amazing the difference in results that occurs when patients actually see their total bill!!

> idea: promote wellness and preventive care: some insurance companies give a financial incentive to exercise: go to the gym three times a week for six months and get $100; or actually take the medicine prescribed by your doctor and receive lower insurance rates.

> idea: look at what works: the Federal employee health insurance program: they have [at least] three insurance companies [if not more] compete to sign up potential insureds; to deal with "pre-existing conditions" they have open-enrollment windows.

> idea: liberalize Section 125 Flexible Spending Account rules to allow people to roll over unused funds from one year to the next (the savings are worth the tax "cost", you myopic political types!!), which allows people over time gradually to "self-insure" by increasing their deductibles / sign up for a higher coinsurance option (and it also allows people during their working years to accumulate funds to pay for inevitably higher healthcare costs during retirement). You can still tax whatever's left when they die (though a spousal rollover would be nice!).

> idea: create a specialized court system for medical malpractice cases (similar to how bankruptcy cases, or tax disputes, or patent law disputes, or trademark infringement cases, all have specialized courts), so that people who understand the issues and have the experience and knowledge to assess the claims clearly and fairly (some physician groups have created self-insured malpractice insurance companies; they know who the risky ones are and keep them out, thereby lowering their malpractice insurance premiums substantially).

> idea: charge higher rates for unhealthy behaviors: it is not unusual for smokers to be charged a higher premium than non-smokers, for example....might we extend this concept? charge the morbidly obese more than people who are "merely" overweight? (it's already legal and widely accepted in life insurance in all US jurisdictions)


These are some of many examples that illustrate why, until this bill, insurance regulation was exclusively a state prerogative: because the people and situations across this great nation are so varied, it is essential to allow each state to tweak the rules to fit their own unique circumstances (although allowing interstate sales of a stripped-down "basic" policy might be nice too, as long as the features were standardized....)



While the existing law has myriad breakdowns, the biggest one of all is that the math doesn't add up. Accounting 101: inflows must equal outflows (i.e., if a=b then b=a). However, by statute, the law tries to enforce inflows < outflows. that can never work. It reminds me of the (perhaps apocryphal) story of the Indiana state legislature attempting to change the value of pi by statute...fortunately for them that law was voted down after engineers testified that if the value of pi were to be changed all the bridges in the state would collapse. At least in that case they listened to the professional experts and did not pretend to be smarter than everyone else!

There are plenty of innovative ways to address the failures and breakdowns described; it is truly a shame that none of them made it into this bill.

[FlagDUDE08]

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

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.

Trying to please everyone is unrealistic. It gets us into the mess we're in now. This is why I don't like let's-be-friends centrists or people who put their emotions ahead of their brains. You don't think it's realistic because you're too wrapped up in your feelings. I think don't work don't eat is absolutely perfect. Maybe with that, people in this country will once again have some character about them.

[DrDemento]

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 $.

Right on the button. Many years ago we had a fellow come in with a large facial skin cancer. Jenny explained what it would cost but he said he had no money and no insurance. We did the excision and repair anyway. Told him that we would treat him the same as everyone else who paid-on one condition. That he did not go around advertising that we treated him for free since i was sure everyone else would come in and ask for the same consideration. He owned a chicken farm-and about 3 weeks later he showed up at the office with 6 dozen eggs for me. He did not have to, but he felt better doing it. When we got home we found that he had hand candled them and selected only double yolk eggs for us. Best freakin omelets we have ever had! The fellow sent me so many other patients we lost count. In those days no one demanded anything from us and most everyone appreciated what we did and how we did it.

[joecct]

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

FreshFish -- most federales have more than 3 health plans to choose from. Here in MD, I have (I think) 10+ all with various options. But the concept is there and why not open the FEHBA to the nation??