One of the hurdles impeding health insurance reform is convincing those already with insurance that the changes will benefit them.
Indeed, according to most polls, more than 3 in 4 are satisfied with their own care, and according to The New York Times’ David Leonhardt, “Americans say they want change, but they also want to preserve their own status quo.”
But, the status quo cannot be preserved if we’re serious about controlling costs.
A recent editorial in the Washington Post shows the delicate situation facing the President. In his speeches, he glosses over what it means to cut costs, instead, referring to Matrix-like analogies of choosing the red pill or the blue pill when it comes to choosing medical treatments. But the situation is far more nuanced than that:
What if the pricey blue pill is actually better than the cheaper red one? What if it’s better but just a little bit? What happens when a yellow pill comes along, costing twice as much as the blue? What happens if there’s a new procedure that cures the ailment, but at an even bigger cost?
And there’s no doubt that cutting costs will require saying no, meaning the average patient will have to be affected. And that’s the conundrum facing reformers during this current iteration of reform.
In other words, having it both ways, wanting change yet maintaining the status quo, will be close to impossible if health care costs are truly to be contained.
Related posts:
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- Cutting health care costs means reducing utilization
- AMA: Curbing the rise in health care costs is key to health-system reform
- That’s one way to cut health care costs
- "Socioeconomic status is the strongest predictor of health"
{ 31 comments }
The Matrix-pill analogy was worth a chuckle, thanks.
I respect Obama for putting this on the table, since health care reform has ruined many politicians before him. I do wish a comprehensive national dialogue would be given more time to find some consensus, rather than rushing to get it over with.
It would be nice if all this talk were governed by a few guiding principles, like fairness and justice, which have always been the beacons of enlightenment. The specifics are so divisive, so I’ll only mention that United Health’s CEO should not make $100,000,000+ a year, doctors shouldn’t have to worry about their own financial ruin with every difficult and defensive decision they make, procedurally oriented fields should not be so lavishly rewarded while the foundation of good health care systems, primary care, wallows in red tape and red ink, and people in general should have access to health care, however it gets paid for, in a modern society.
I’ll be testifying to Congress on these issues.
Once they return my call.
Who is/ what is this entity that says “no”? People determine for themselves what is the optimal treatment and the acceptable cost. That’s not your concern. You are a doctor.
You tell all. You offer all. You tell of possibilities. You tell of limits. Others can work out what they are willing to pay.
Has the position of Tonsil Czar been filled yet?
Sarah W
We physicians are also patient advocates. If we know one medication or procedure is better than another do we not have a professional and moral obligation to help the patient obtain that treatmentt or had you rather we leave it to you to sort out the details after we have fully informed you of your options.
Kevin,
Your post begs the question:
Are we really serious about controlling costs?
I don’t think that controlling costs is really what the American public wants. I think we want access to the best care, and we don’t want cost to be a barrier.
That’s a different thing from controlling cost. Not recognizing this is among the reasons why the effort to sell health care reform is failing.
Evan
Physicians are not patient advocates. They are physician advocates. If patients benefit that’s a nice, but ancillary result.
This statement illustrates the point: “But, the status quo cannot be preserved if we’re serious about controlling costs.”
Kevin routinely argues for reform, but the minute that reform includes cutting physician pay, he argues for the status quo or even increasing that pay.
What is this, honesty? You mean most will be worse off than they are presently, under the proposed health care “reform”? It’s nice to finally see it frankly addressed. In short, it will cost the average consumer more, the average consumer will receive less care and wait longer for it, all for the good of an estimated 10 million. More than anything else, it demonstrates the height of arrogance of central planning: “Don’t worry, we know best.”
Before we accept that the powers that be do know best, there are some basic questions that need real answers: Can we afford it? Is it worth it? Will my care suffer? Why are we doing this? By my estimate, we’re at No, No, Yes, and Don’t know. Not reassuring. This bill is not what we need, and we should have the courage to say no.
Here’s how they plan to cut costs… Medicare payment for all. Sounds good, doesn’t it? Not much efficiency talked about there, just more of the same “let’s go after those wealthy doctors.” See below.
But the concessions Waxman made to the so-called Blue Dog Democrats infuriated House liberals. They denounced the proposed new structure of the public plan, which was originally designed to be based on Medicare rates. The new structure says rates would be negotiated with providers as occurs now with private companies, which could result in more expensive care.
“This agreement is not a step forward toward a good health care bill, but a large step backwards,” 53 Progressive Caucus members said in a letter to House leaders Thursday. “Any bill that does not provide, at a minimum, for a public option with reimbursement rates based on Medicare rates — not negotiated rates — is unacceptable.”
At a news conference liberal lawmakers threatened to vote against the bill if it comes to the floor without a stronger public plan. Rep. Anthony Weiner, D-N.Y., an Energy and Commerce member, said liberals probably had enough votes to block the Blue Dog deal in committee.
For the full article, http://news.yahoo.com/s/ap/20090730/ap_on_go_co/us_health_care_overhaul
“The needs of the few outweigh the wants of the many”
Trenchdoc, but It is left to us to sort out the details. Patients (or their legal proxies) do ulitmately make the choice about how to proceed, according to individual appraisal of risks, benefits, and costs. I approve of your idea that you are bound by a professional duty to the patient, and not “the system”, and who could disapprove of you giving patient’s your best evaluation and counsel?
Matt
Your physician may not be your advocate but I am my patient’s
advocate. If I was only my own advocate I could have made so much
money that I could have retired 10 years ago. You of all people on
this blog should know better than to generalize.
To all of the smug citizens who are happy with their health coverage under the “status quo”, I say wake up and realize that the “status quo” is not under your control. We were all happy with our defined benefit pension plans in a former “status quo” but most of those pension plans are gone. If your employer goes out of business and you lose your job, your “status quo” is gone along with your health coverage. This is the whole point of health care reform. Somehow there needs to be a certain level of decent health care available regardless of the generosity and financial strength of your employer. Just think of what life in this country would be like if your ability to send your kids to school was based upon whether you whether you maintained a job at a company that offered this benefit.
I’m talking politically. Their advocacy is for them. Not begrudging it, just not buying it.
But overall I would not say that’s true on an individual basis. Although I have seen a lot of physicians lately who will not assist their patients who are trying to get on disability regardless of the legitimacy or testify for them when they’re injured and need help.
I have heard anecdotally that patient wait times in the UK are at least in part to the slow pace of the physican’s day in the UK. Stated another way, UK physicans are state salaried employees who over time have adopted the same attitude that we see in the US at the DMV, “no hurry-no worry”.
Contrast that approach with that of a hypothetical large health care organization that requires physicians to see X number of patients per day. I suspect that most self-employed physicans in the U.S. also have a similar patients/day value in mind, at least with respect to their office overhead and breakeven.
I would be interested in your thoughts.
i agree with “a skeptic.”
furthermore, it is naive to think that we are truly in charge of our health care choices. there are many forces, such as insurance co.s, pharmaceutical co.s, employers, etc., influence the kinds of decisions we make. the problem is the aversion to gov interference.
it always puzzles me how we are so much more comfortable when the income and market forces ration our choices but when gov does it, things get complicated. my main concern with the notion of medicine as business that in medicine market cannot force itself to correct. majority of consumers have to listen to their doctors for the best option to fix their health problem. the patients cannot diagnose and treat a disease – they cannot do it themselves as fixing their roof or car. some people argue that if the patients do not like the price or the services they are getting, they can shop around. however, most people wouldn’t even know if the price or the products was right in the first place. we all know instances of persistent mismanagement of a health problem until it is too late – if only the patient had enough training to diagnose and treat their own problems…
Anecdotes are just anecdotes.
The data showing a significant difference in outcomes between our healthcare and UK is lacking.
Any change anywhere in America affects status quo. And I think that the working poor should insist on better, more reliable, long-term health coverage (NOT Medicaid, not third-rung coverage in an opt-in/opt-out multi-tier system). Otherwise, the working poor should just simply refuse to work.
This is long… bear with me…
Where are the patients in all these discussions? Let us face it, many of us patients want ‘increased’ heathcare availability at ‘reduced’ costs. That is just human nature… however, with a little more education, we will discover that just more of something does not equate to good care. Several years ago, I believed that the more tests and the more advanced the technology, the better care my family and I were getting. However, over the last 8 years, I have come to learn that is not the case. See the following examples:
By not going to the ER over the weekend for sinus blockage due to the common cold and instead waiting for the drs office on Monday saves a few hundred dollars. Telling mothers no (heck No!!!) when they insist that their child with the common cold needs antibiotics. They might not be on medicaid (cost to the public), but it is very likely they are on their employer sponsored health care plan. These individual little costs add up to huge medical costs for all employees combined; meaning, employee premiums go up the following year!
We were rear ended some time ago which resulted in minimal damage to the car. Other than being scared, we, the passengers felt quite okay. We drove ourselves to the local urgent care clinic and that was because there was a child (otherwise we felt well). At the clinic, dr asked us multiple questions and did a through physical exam, determined no lasting damage and said in his opinion we were fine. One of the passengers with us insisted on multiple scans,etc. The dr advised that if it would make him happy, then he can order requested tests but in his opinion they were not necessary. Tests ordered for him, everything came back fine. We did not take the tests, three years later we are fine. We all had the insurance and the financial resources to pay for the additional testing but to what end? Either you trust your dr and that he knows what he is doing, or you trust the tests. The latter are a tool to assist the dr. I have come to understand that better healthcare does not mean more testing. We need to educate the public that we do not need every concievable test out there to get excellent healthare. Just by reducing these frivolous CTs, MRIs, etc, etc, we could save a bundle.
The public needs to be told that if they want to see reduced healthcare costs, they need to do their part. Please take your cholestrol, blood pressure and diabetes medication as advised by your dr. The drugs will cost you less than the heart attack and stroke you will surely get if you ignore the dr!
Everybody is talking about reducing dr salaries, increasing gov funds, who voting where, but no where is anybody giving an articulate plan on what the patient can do to reduce healthcare costs.
Chronic Patient
UK – US Differences
My comment was not directed at patient outcome data. It was rather a query about the relative efficiency of the delivery of care. My suspicion is that if UK physicians had the same work output as US physicians, the long patient wait times that are thrown around in the health care debate would have less relevance.
Regards
-DL
6 Matt July 30, 2009 at 5:26 pm
Physicians are not patient advocates. They are physician advocates. If patients benefit that’s a nice, but ancillary result.
Matt, there are some of us (many of us) who truly do care about our patients.
However, if you still believe your words that we are just advocates of ourselves, then there is an even better solution for people like you — the magic of the free market. That way, we doctors who care about ourselves, will bust our butts making you happy so that you will continue to be our patients. This way, YOU get to dictate your care, because if it doesn’t satisfy you, then you have the power to take your business elsewhere.
If you compare your level of satisfaction with things that you have choice and control over (restaurants, stores, hairstylists) vs those which you have little control over (politicians, public school teachers, post office employees) you might have a better idea of whether medicine is better off being free market vs a government controlled monopoly.
I don’t begrudge anyone a government “OPTION” for their healthcare, but please don’t take away my free market option for my family’s healthcare.
As far as costs go, part of the problem is that most people (doctors and patients) seem to think that “more care is always better”. And since most patients’ costs are not directly paid (i.e. through insurance), most patients do not consider “is this the best value in treatment?”.
If people self-paid for their medical care, then they might be a bit better about choosing the best value instead of always choosing more. Unfortunately, medical care is expensive enough that most people cannot effectively self-insure all of their potential medical expenses (which is why most care is paid for through some insurance scheme), and many people put off even small medical expenses and allow small medical problems to turn into bigger and more expensive ones later (which is why the theoretically more cost effective catastrophic cost medical insurance is uncommon and unpopular).
Unfortunately, medical insurance is often a monopoly or oligopoly to most people. Most people with employment based medical insurance have just one to three choices of medical insurance plans through their employers, each with its own limitations on which doctors can be seen to get full payment. And they have plenty of bureaucracy, denying valid claims for no reason, etc..
The medical insurance system today in the US has degraded to the point that all of the feared problems of government universal insurance schemes are true today, but without any of the advantages of universal insurance schemes.
I don’t see the problem with a dual system of a basic government health plan competing with private plans giving people a choice of whether or not they want to pay more for private plans offering more or different services. We have dual public/private educational systems. People have a choice, but at least everyone has access to the public system with the option if paying more for private school if they can or want to. There are public/private choices for recreation. You can either go to a public park or beach for free or a minimal fee or you can pay a lot of money to go to a fancy private theme park. We have two tiered systems in many aspects of everyday life. If you’re arrested and have few resources, you get a public defender. He/she may not be the best lawyer in town, but at least you get something. Right now if you’re sick and can’t afford medical care, you may be completely out of luck. Yes, there will be rationing in a government plan. I think the public is now mature enough to get past the Harry and Louise BS and understand that having something is better than nothing.
“basic government health plan competing with private plans”
The key word there is competing. Can one realistically believe that the government would allow its health plan to go bankrupt? If it cannot be allowed to go bankrupt, it is not a fair competition, and private plans will go out of business. In government, the more something fails, the more money is thrown at it (public schools, etc.), while in the marketplace, failure is rewarded with termination.
IVF-MD said: “…there is an even better solution for people like you — the magic of the free market…f you compare your level of satisfaction with things that you have choice and control over (restaurants, stores, hairstylists) vs those which you have little control over (politicians, public school teachers, post office employees) you might have a better idea of whether medicine is better off being free market vs a government controlled monopoly.”
Without getting into a debate over the fictional “magic” of the free market, it needs to be empasized, over-and-over again, that there is no such thing as a “free market” American health care system in the first place. First,
as one of the responders points out, the private health insurance racket is an oligopoly — a few major providers collude with one another for their personal profit (and everybody else’s loss).
Secondly, even if we remove private insurance from the setting, the deliberately tiny number of available medical school admissions and the even tinier number of subsequent residency training positions artificially contracts the size of any physician market available to patients. Why not allow for more licensure of outside-USA-trained specialists, for example? Answer: the AMA.
Henry Blankett makes a very valid point. The way I see it, the idea of getting health care for everyone is a pipe dream because the supply of physicians is artificially limited. I’m a US citizen attending medical school in the Caribbean. In order to graduate, I have to pass Step 1, Step 2 and Step 2 CK. I have to go through residency training just like everyone else. Then I’ll have to pass step 3. After all of that, I’ll be eligible for a license in about 40 states. Why not 50? Because states have been lobbied by existing physicians to keep out competition.
Somehow, in medicine, the big boys get the government to keep out their competition. ~30 states have “certificate of need” laws requiring you to prove that you aren’t “duplicating services” if you want to open a hospital. Law prohibit people from buying insurance across state lines. Hospitals have to get the permission of the ACGME to increase the number of residents they hire. Everywhere, the big boys get protected and the patients get buggered. Now they want the government to get more involved? I can guarantee you that it won’t be patients OR doctors who benefit from this new scam.
Trenchdoc, I’ll give you a quote: “To each according to his needs, from each according to his abilities.” Sound familiar? This was tried for 70-odd years. Didn’t work too well.
Man has a right to the product of his labor, to appropriate that for the benefit of a few seems to me to be wrong. Government spending should benefit all: see spending on defense, highways, even (wince) the USPS. Redistribution of wealth is not the proper role of government.
Regarding “find the data” detailing outcomes differences between the UK and the US: this kind of data cannot be accomplished because the two types of health care systems are significantly different.
For example: you can go to the guidelines clearinghouse and find the statin guidelines for the UK. If you read them, you’ll discover that the UK universal coverage only covers a statin in the most dramatic of circumstances, compared to our NCEP guidelines. When the ENTIRE APPROACH to treatment of an illness differs, then direct comparisons of outcomes cannot be made.
We can look now at the CHD stats, and notice that the US has a slightly lower rate of CHD compared to the UK, yet the differences don’t appear to be large. (Figures available on Americanheart & UK heart websites.) You simply can’t use that as information to suggest there are no differences in outcomes. Our rates of obesity, diabetes, hypertension, etc. are higher than that in the UK, yet we are more proactive about treatment of hyperlipidemias. Considering these issues, there actually might be a huge disparity between UK and US outcomes–but you cannot appreciate these with direct comparisons. That’s an erroneous way to discuss this issue.
Same with Canada.
I feel a tad awkward saying that solutions ARE at hand and, further, they are NOT that difficult to comprehend or implement.
I invite interested persons to see two entries at http:doc2dochealthcarereform.com : They are “Successful Ideas” and “47M – 37M = 10M”. Together they inform that the problem is not as severe or as intractable as many want us to believe.
Healthcare resources are finite, demand for them can be practically infinite. Therefore there MUST be some sort of rationing. It will be either by market mechanisms or third-party authorities, probably government.
Here is an example to illustrate the difference:
You have a fatal condition. There is a certain cure. You will need quarterly doses for two years. Each costs $38,000. Which do you prefer:
1) You appreciate that you cannot afford it and either: a) get your affairs in order or b) initiate heroic efforts, including contacting all relatives and friends, holding raffles and bake sales, auctioning off “one year of (LEGAL) servitude”, borrowing from a bank – and raise the money for treatment.
— – — – OR — – —
2) You are told that, even if you happen to have or are able to raise the money, you CANNOT be treated because the cure has been determined illegal due to its high cost.
?????
OMG!!! — – It’s a no brainer to me.
PS – Do NOT write that these options will not work for the poor. That is elitist nonsense. Pilot programs have succeeded in the Medicaid population. (The money is granted to them, and more than made up through health care cost savings.)
I would like to see a break down of the stats shoing that 70% of Americans are satisfied with their coverage. What percentage of these had to use their insurance for significant health care problems? What percentage of people who had to use their insurance for significant problems are satisfied with their coverage (or were at the time of the problem)? What specific insurance coverage (i.e. Kaiser, United Health Care, Medicare A and B) most satisfied people who had to use it for serious medical problems?
Health Care Reform: American’s quit sitting on their fat asses, eating themselves to death, smoking, drinking to liver failure and stroking out on drugs. Or maybe just have the Govt not pay for treatment of conditions that are completely preventable. Medicare wants to not pay for “never events.” A similar approach to patients could (if the incentive actually motivated their lazy asses) results in both decreased costs AND improved health.
Win win win.
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