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  • wideopenspaces
    replied










    ENT Doc-

    I’m losing faith in a non-single payor system. It has to be done well, but I think that may be the ultimate solution to reasonable costs and reasonable access to care.

    And for heaven’s sake, we need some death panels. All the health care you consume cannot be an entitlement.
    Click to expand…


    Tell me the last big government program that was “done well”, didn’t bust through its budget, doesn’t suffer from gross inefficiency (aka waste of taxpayer dollars), and that doesn’t substantially contribute to our national debt.  All programs start with good intentions.  They just never live up to the hype.

    Again, there are smart people out there (many of whom come to discussion boards such as this to discuss and debate).  Can we really not think of ANYTHING that would be superior to giving the most inefficient and incompetent segment of our market power over that which we hold most dear?  Our government doesn’t have a track record that warrants handing it such power.  I’m serious – can anyone here not think of any models of care that would reduce costs that doesn’t involve big government single payer?  I would hope those of us in medicine, with all our wit and wisdom, would have devoted some time thinking about how to accomplish this task.  Any takers?
    Click to expand…


    I’ll bite.  The cliffnotes version of my plan:

    1) National healthcare plan, Medicaid for every legal resident, birth through 80 years of age.  You get fired (after 3 warnings) if you abuse it (ambulance for your 20th ER visit for belly pain, 3+ visits for alcohol detox–I saw 2 of each of these patients today).  This also includes folks that don’t take their meds, maintain an unhealthy weight, smoke, etc.  Yes, this lifestyle stuff is vague and would need rigorous protocols.  Even if we find the discussion awkward, accountability needs to play a role.  I’d like to have mandatory hospice/comfort care (the nefarious death panel), but I don’t trust who would be in charge of that.  Perhaps low hanging fruit, like if you are a Child’s C or have CRF with no plan for a transplant.  Providers are covered as government employees for purposes of medical liability.

    2) Private insurance.  You are welcome to pay for this as a supplement to Medicaid or if you lose your Medicaid.  If you want to to get dialysis for 10 years, or get your massive transfusion protocol for your bleeding esophageal varices, this is your option.  You will get that knee MRI faster, the fancier surgical post-op lounge, maybe even a fancier and faster surgeon.  Yes, this will create two standards of care.  I am pretty sure that if Lebron James sprains his knee, he gets a different standard of care than me; I am comfortable with this.  Providers must buy their own malpractice.

    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can’t afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws.

    4) You get nothing.

    Of course this is going to be expensive, but I suspect there would be “savings” realized in the rationing of care, specifically no more wasting money on futile care that could be instead funneled back to preventive health.  Heck, maybe there’d even be enough left over to give extra to education and infrastructure.

    Perhaps this is all too callous, but our current system doesn’t feel sustainable as presently we seem to guarantee that everyone gets everything they want no matter what.  Particularly when combined with the boomers starting to have their age catch up with them and an entire generation of children that are demonstrably less healthy than their parents were.

     
    Click to expand...


    I'm getting the feeling that you don't think addiction is a medical condition?

    Leave a comment:


  • RogueDadMD
    replied


    You betcha.  Specifically mentioned the dinghy just for you!
    Click to expand...


    I noticed!  Even a dinghy may be a bit generous, but I'm not cruel.  We'll let him float away gently into the horizon.

    Leave a comment:


  • G
    replied





    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can’t afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws. 
    Click to expand…


    Thanks for incorporating me into the new system.  ????
    Click to expand...


    You betcha.  Specifically mentioned the dinghy just for you!

    Leave a comment:


  • RogueDadMD
    replied


    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can’t afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws.
    Click to expand...


    Thanks for incorporating me into the new system.  

    Leave a comment:


  • AR
    replied
     

     

     




    I know it’s all just political posturing and I shouldn’t let it bother me, but the media conversation the last few days about health care changes is starting to grate on me. I mean, I don’t think the Republican plans are super, just like I didn’t think the Democratic plan was super. And neither of them do anything to solve the real issue anyway. I wish those knuckleheads would sit down together in a closed room and come up with some sort of compromise so they can work on reducing costs- the real issue.
    Click to expand...


    This whole post made me chuckle.  I mean, I get where you're coming from, but if you're looking for some sort of pat on the back from the less fortunate in society, then you're going to be waiting a long time.

    This first part was actually bad though.  Painting any sort of equivalence between Obamacare and Trumpcare by characterizing them as both not "super", is just a false equivalence.  They might both be sub optimal, but the plan that passed the House is far, far worse (and what's being discussed in the senate is in the similar).  They not even in the same league of badness.  And I can comfortably say that even as someone who would save quite a bit of money with Trumpcare.

    To think of them as similarly bad or describe them that way is the same error people make when they say that people with incomes of $2 million/yr and $20 million/yr are rich.   It's technically true in one sense, but completely misses the reality of the situation.

    Leave a comment:


  • kingsnake
    replied
    Hey, relax,  "You didn't earn that!"

    Leave a comment:


  • The White Coat Investor
    replied







    The issue with a market based solution is that the components that must be in place for a market to function are not in place.
    Click to expand…


    And those components are…

    And how to adresss that is…
    Click to expand...


    Transparency of pricing and skin in the game.

    Mandated prominent posting of prices and insurance structural changes- eliminate employer provided health insurance and increase co-insurance/co-pay for Medicaid, Tricare, Medicare etc.

    Good luck with either of those.

    https://www.ncbi.nlm.nih.gov/pubmed/15046128

     

    Leave a comment:


  • ENT Doc
    replied
    StarTrekDoc and G bring up some important points IMO.  You need to have accountability - otherwise you have the problem of moral hazard where people overutilize care.  That's where the cost sharing comes into play - for EVERYONE, at least at some $ amount - the benefits of which were shown by the Rand Health Insurance Experiment.  G's plan (public + private with potentially difference in care) sounds like Australia.  So that concept does work elsewhere.  As y'all have noted, this is an insane problem to tackle due to special interests.  From a strategy standpoint this issue is best addressed organically IMO.  As much as I am anti big government, they do have a role to play in my ideal scenario.  Keep in mind there's no free lunch and one or more groups will lose out in any scenario.  That being said, if the government created an environment that actually incentivized free market competition based on value then we'd be somewhere.

    The only way to achieve that under the current model (from a payment perspective) is a) completely change payments to quality-based, or b) internalize insurance into a given hospital system.  If b) happened there would be no reason to modify payments - hospitals would be immediately incentivized to streamline processes, cut costs, reduce waste and redundancy, etc.  The second thing the government could do is require full disclosure, down to the clinic/physician level, of quality data (the numerator of the value equation).  This is what I believe WCI was getting at.  In any other free market system we have transparency of value.  You know what you're getting (quality, price...or value) when you buy a Starbucks coffee vs McDonalds or a Ferrari vs Honda Accord.  Companies compete on that level only because there is transparency.  That's where competition works.  Competition, which is the superior way to bring down costs, doesn't work because we don't have transparency.  If we did a) above I believe that over time we'd evolve to b) anyway.  After a while, hospital systems will have optimized their efficiency to where the 3rd party payer becomes a value extracting mechanism.  So who loses here?  Insurers, for one - at least the overall construct because many of the people internal to the insurer would still find work in hospital systems to do the heavy actuarial lifting and claims processing.  Second are private practice groups - and that sucks.  Still trying to solve that problem...

    In either a) or b) above you have a superior solution to government single payer because you have superior market-based efficiency rather than a monopoly dictating low prices.  Those kinds of policies (see minimum wage or price controls on gas) always create an inefficiency in the market that hurts everyone.  We should avoid that at all costs.

    Leave a comment:


  • ENT Doc
    replied




    The issue with a market based solution is that the components that must be in place for a market to function are not in place.
    Click to expand...


    And those components are...

    And how to adresss that is...

    Leave a comment:


  • G
    replied













    ENT Doc-

    I’m losing faith in a non-single payor system. It has to be done well, but I think that may be the ultimate solution to reasonable costs and reasonable access to care.

    And for heaven’s sake, we need some death panels. All the health care you consume cannot be an entitlement.
    Click to expand…


    Tell me the last big government program that was “done well”, didn’t bust through its budget, doesn’t suffer from gross inefficiency (aka waste of taxpayer dollars), and that doesn’t substantially contribute to our national debt.  All programs start with good intentions.  They just never live up to the hype.

    Again, there are smart people out there (many of whom come to discussion boards such as this to discuss and debate).  Can we really not think of ANYTHING that would be superior to giving the most inefficient and incompetent segment of our market power over that which we hold most dear?  Our government doesn’t have a track record that warrants handing it such power.  I’m serious – can anyone here not think of any models of care that would reduce costs that doesn’t involve big government single payer?  I would hope those of us in medicine, with all our wit and wisdom, would have devoted some time thinking about how to accomplish this task.  Any takers?
    Click to expand…


    I’ll bite.  The cliffnotes version of my plan:

    1) National healthcare plan, Medicaid for every legal resident, birth through 80 years of age.  You get fired (after 3 warnings) if you abuse it (ambulance for your 20th ER visit for belly pain, 3+ visits for alcohol detox–I saw 2 of each of these patients today).  This also includes folks that don’t take their meds, maintain an unhealthy weight, smoke, etc.  Yes, this lifestyle stuff is vague and would need rigorous protocols.  Even if we find the discussion awkward, accountability needs to play a role.  I’d like to have mandatory hospice/comfort care (the nefarious death panel), but I don’t trust who would be in charge of that.  Perhaps low hanging fruit, like if you are a Child’s C or have CRF with no plan for a transplant.  Providers are covered as government employees for purposes of medical liability.

    2) Private insurance.  You are welcome to pay for this as a supplement to Medicaid or if you lose your Medicaid.  If you want to to get dialysis for 10 years, or get your massive transfusion protocol for your bleeding esophageal varices, this is your option.  You will get that knee MRI faster, the fancier surgical post-op lounge, maybe even a fancier and faster surgeon.  Yes, this will create two standards of care.  I am pretty sure that if Lebron James sprains his knee, he gets a different standard of care than me; I am comfortable with this.  Providers must buy their own malpractice.

    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can’t afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws.

    4) You get nothing.

    Of course this is going to be expensive, but I suspect there would be “savings” realized in the rationing of care, specifically no more wasting money on futile care that could be instead funneled back to preventive health.  Heck, maybe there’d even be enough left over to give extra to education and infrastructure.

    Perhaps this is all too callous, but our current system doesn’t feel sustainable as presently we seem to guarantee that everyone gets everything they want no matter what.  Particularly when combined with the boomers starting to have their age catch up with them and an entire generation of children that are demonstrably less healthy than their parents were.

     
    Click to expand…


    #1 – that’s not medicaid — no one gets kicked off medicaid no matter how bad acting or noncompliant.  How about that IBS or Ehlers Danlos patient with belly pain?  Or that Crohn’s patient with flares calling the ambulance?  Not so black/white and who decides the shade of grey in those protocols — hence the line doesn’t get drawn.   Because then they get dumped back into the shadows as won’t get even #3 and end up in the ED with #4 option which will still have the necessity to treat.   Death panel started at 80 yo.   Yikes.  Indeed Euthanasia for 80+ … take that our current day ‘greatest generation’ folk.   You all get nada for WWII.

    –I do like a mandatory ethics/utilization board once a certain threshold of resources are utilized and determination of what is reasonable and limits and final expectations before deemed heroic measures.

    +++++

    My Pie-in-the-sky thoughts:

    – This is America.  Land of special interests.  Private Insurance and Multiple regional health care systems will remain the way.

    Two National vertically integrated systems can arise to provide a counterweight if we give it some push —  Kaiser and VA which is turned into a public access system (at same time, Veterans’ care can expand into the private sector without barriers–no, today’s VA access is NOT that).

    –Additional counterweight to premiums on the private insurance side —  Tricare Prime is opened up for public access with set premiums and provide a national insurance that’s potable and pays competitive rates.   This will act as an anchor to 3rd party insurers as a price controller.

    –Continue evolution of Medicare and Medicaid programs to a value based delivery system and bundled services, away from procedure oriented services and RVU based models that skew toward procedures /production over outcomes and validations with reports and subsequent disbursements to health systems.  This sets the standards which insurance companies will adopt for the general population beyond the ‘safety net’ of medicaid and medicare.

     
    Click to expand...


    Laws will change by necessity.  You're right, it's not the Medicaid of 2017 so call it something else.  You can lose it and I agree that the line is squishy.  Arriving to hospital via ambulance once a year for an IBD flare, sure; how about once per month?  How about the cannabis hyperemesis kid that I saw today who has been to hospital 5 times this month?  Perhaps he will come back tomorrow to make a cool 6 trips for June.  Come on, there is a difference between not having insurance (or requiring someone to purchase insurance not subsidized by the taxpayers) and euthanasia.  I anticipate a time when there is no longer mandatory delivery of care, and/or a regression to a time when charity care is concentrated at specific hospitals.  I feel like we're already effectively seeing that with the explosion of free-standing EDs put up in affluent zipcodes.

    You're right, special interests (to include us!) and a whole lot of inertia will make it tough to reform things....

    Leave a comment:


  • StarTrekDoc
    replied










    ENT Doc-

    I’m losing faith in a non-single payor system. It has to be done well, but I think that may be the ultimate solution to reasonable costs and reasonable access to care.

    And for heaven’s sake, we need some death panels. All the health care you consume cannot be an entitlement.
    Click to expand…


    Tell me the last big government program that was “done well”, didn’t bust through its budget, doesn’t suffer from gross inefficiency (aka waste of taxpayer dollars), and that doesn’t substantially contribute to our national debt.  All programs start with good intentions.  They just never live up to the hype.

    Again, there are smart people out there (many of whom come to discussion boards such as this to discuss and debate).  Can we really not think of ANYTHING that would be superior to giving the most inefficient and incompetent segment of our market power over that which we hold most dear?  Our government doesn’t have a track record that warrants handing it such power.  I’m serious – can anyone here not think of any models of care that would reduce costs that doesn’t involve big government single payer?  I would hope those of us in medicine, with all our wit and wisdom, would have devoted some time thinking about how to accomplish this task.  Any takers?
    Click to expand…


    I’ll bite.  The cliffnotes version of my plan:

    1) National healthcare plan, Medicaid for every legal resident, birth through 80 years of age.  You get fired (after 3 warnings) if you abuse it (ambulance for your 20th ER visit for belly pain, 3+ visits for alcohol detox–I saw 2 of each of these patients today).  This also includes folks that don’t take their meds, maintain an unhealthy weight, smoke, etc.  Yes, this lifestyle stuff is vague and would need rigorous protocols.  Even if we find the discussion awkward, accountability needs to play a role.  I’d like to have mandatory hospice/comfort care (the nefarious death panel), but I don’t trust who would be in charge of that.  Perhaps low hanging fruit, like if you are a Child’s C or have CRF with no plan for a transplant.  Providers are covered as government employees for purposes of medical liability.

    2) Private insurance.  You are welcome to pay for this as a supplement to Medicaid or if you lose your Medicaid.  If you want to to get dialysis for 10 years, or get your massive transfusion protocol for your bleeding esophageal varices, this is your option.  You will get that knee MRI faster, the fancier surgical post-op lounge, maybe even a fancier and faster surgeon.  Yes, this will create two standards of care.  I am pretty sure that if Lebron James sprains his knee, he gets a different standard of care than me; I am comfortable with this.  Providers must buy their own malpractice.

    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can’t afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws.

    4) You get nothing.

    Of course this is going to be expensive, but I suspect there would be “savings” realized in the rationing of care, specifically no more wasting money on futile care that could be instead funneled back to preventive health.  Heck, maybe there’d even be enough left over to give extra to education and infrastructure.

    Perhaps this is all too callous, but our current system doesn’t feel sustainable as presently we seem to guarantee that everyone gets everything they want no matter what.  Particularly when combined with the boomers starting to have their age catch up with them and an entire generation of children that are demonstrably less healthy than their parents were.

     
    Click to expand...


    #1 - that's not medicaid -- no one gets kicked off medicaid no matter how bad acting or noncompliant.  How about that IBS or Ehlers Danlos patient with belly pain?  Or that Crohn's patient with flares calling the ambulance?  Not so black/white and who decides the shade of grey in those protocols -- hence the line doesn't get drawn.   Because then they get dumped back into the shadows as won't get even #3 and end up in the ED with #4 option which will still have the necessity to treat.   Death panel started at 80 yo.   Yikes.  Indeed Euthanasia for 80+ ... take that our current day 'greatest generation' folk.   You all get nada for WWII.

    --I do like a mandatory ethics/utilization board once a certain threshold of resources are utilized and determination of what is reasonable and limits and final expectations before deemed heroic measures.

    +++++

    My Pie-in-the-sky thoughts:

    - This is America.  Land of special interests.  Private Insurance and Multiple regional health care systems will remain the way.

    Two National vertically integrated systems can arise to provide a counterweight if we give it some push --  Kaiser and VA which is turned into a public access system (at same time, Veterans' care can expand into the private sector without barriers--no, today's VA access is NOT that).

    --Additional counterweight to premiums on the private insurance side --  Tricare Prime is opened up for public access with set premiums and provide a national insurance that's potable and pays competitive rates.   This will act as an anchor to 3rd party insurers as a price controller.

    --Continue evolution of Medicare and Medicaid programs to a value based delivery system and bundled services, away from procedure oriented services and RVU based models that skew toward procedures /production over outcomes and validations with reports and subsequent disbursements to health systems.  This sets the standards which insurance companies will adopt for the general population beyond the 'safety net' of medicaid and medicare.

     

    Leave a comment:


  • G
    replied







    ENT Doc-

    I’m losing faith in a non-single payor system. It has to be done well, but I think that may be the ultimate solution to reasonable costs and reasonable access to care.

    And for heaven’s sake, we need some death panels. All the health care you consume cannot be an entitlement.
    Click to expand…


    Tell me the last big government program that was “done well”, didn’t bust through its budget, doesn’t suffer from gross inefficiency (aka waste of taxpayer dollars), and that doesn’t substantially contribute to our national debt.  All programs start with good intentions.  They just never live up to the hype.

    Again, there are smart people out there (many of whom come to discussion boards such as this to discuss and debate).  Can we really not think of ANYTHING that would be superior to giving the most inefficient and incompetent segment of our market power over that which we hold most dear?  Our government doesn’t have a track record that warrants handing it such power.  I’m serious – can anyone here not think of any models of care that would reduce costs that doesn’t involve big government single payer?  I would hope those of us in medicine, with all our wit and wisdom, would have devoted some time thinking about how to accomplish this task.  Any takers?
    Click to expand...


    I'll bite.  The cliffnotes version of my plan:

    1) National healthcare plan, Medicaid for every legal resident, birth through 80 years of age.  You get fired (after 3 warnings) if you abuse it (ambulance for your 20th ER visit for belly pain, 3+ visits for alcohol detox--I saw 2 of each of these patients today).  This also includes folks that don't take their meds, maintain an unhealthy weight, smoke, etc.  Yes, this lifestyle stuff is vague and would need rigorous protocols.  Even if we find the discussion awkward, accountability needs to play a role.  I'd like to have mandatory hospice/comfort care (the nefarious death panel), but I don't trust who would be in charge of that.  Perhaps low hanging fruit, like if you are a Child's C or have CRF with no plan for a transplant.  Providers are covered as government employees for purposes of medical liability.

    2) Private insurance.  You are welcome to pay for this as a supplement to Medicaid or if you lose your Medicaid.  If you want to to get dialysis for 10 years, or get your massive transfusion protocol for your bleeding esophageal varices, this is your option.  You will get that knee MRI faster, the fancier surgical post-op lounge, maybe even a fancier and faster surgeon.  Yes, this will create two standards of care.  I am pretty sure that if Lebron James sprains his knee, he gets a different standard of care than me; I am comfortable with this.  Providers must buy their own malpractice.

    3) Self pay (as in actual cash or credit card) for those that get kicked out of 1 and can't afford 2.  This is where charity comes in, either through provider care or from donations like RogueMD who wish to earmark money for healthcare but not bunkerbuster bombs or the USS Donald Trump battleship/dinghy.  Providers are covered under good samaritan laws.

    4) You get nothing.

    Of course this is going to be expensive, but I suspect there would be "savings" realized in the rationing of care, specifically no more wasting money on futile care that could be instead funneled back to preventive health.  Heck, maybe there'd even be enough left over to give extra to education and infrastructure.

    Perhaps this is all too callous, but our current system doesn't feel sustainable as presently we seem to guarantee that everyone gets everything they want no matter what.  Particularly when combined with the boomers starting to have their age catch up with them and an entire generation of children that are demonstrably less healthy than their parents were.

     

    Leave a comment:


  • The White Coat Investor
    replied
    The issue with a market based solution is that the components that must be in place for a market to function are not in place.

    Leave a comment:


  • amphora
    replied
    I agree with WCI that single payor is the "ultimate solution". And I think both parties recognize that single payor will come about through gradual Medicaid expansion, which is why the Republucabs are so opposed to it.

    Right now, single payor isn't politically viable. But at some point employers will decide it's better for the bottom line to avoid the costs of employee health plans through a single payor system, even if it entails higher taxes.

    Leave a comment:


  • ENT Doc
    replied




    ENT Doc-

    I’m losing faith in a non-single payor system. It has to be done well, but I think that may be the ultimate solution to reasonable costs and reasonable access to care.

    And for heaven’s sake, we need some death panels. All the health care you consume cannot be an entitlement.
    Click to expand...


    Tell me the last big government program that was "done well", didn't bust through its budget, doesn't suffer from gross inefficiency (aka waste of taxpayer dollars), and that doesn't substantially contribute to our national debt.  All programs start with good intentions.  They just never live up to the hype.

    Again, there are smart people out there (many of whom come to discussion boards such as this to discuss and debate).  Can we really not think of ANYTHING that would be superior to giving the most inefficient and incompetent segment of our market power over that which we hold most dear?  Our government doesn't have a track record that warrants handing it such power.  I'm serious - can anyone here not think of any models of care that would reduce costs that doesn't involve big government single payer?  I would hope those of us in medicine, with all our wit and wisdom, would have devoted some time thinking about how to accomplish this task.  Any takers?

    Leave a comment:

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