On the one hand, we should all take charge of our own health and be an active participant in our health care and medical decisions. We should educate ourselves, to a much greater extent than most now do, on our those aspects of our health that would motivate us to see our doctor.

On the other hand, I did not go to medical school. I did not put in those long four years plus additional years of internship and residency. I do not claim to have the breadth and depth of either knowledge or practical experience in observing or diagnosing illness or injury nor do I have the knowledge or experience in prescribing testing or treatment necessary to feel entirely comfortable telling my doctor “No, I don’t think you’re right. I don’t think that’s necessary.”. As proficient as I am at web search and research, I would not stack that up against my family practitioner’s knowledge and experience.

And I can’t even imagine the litigation and defensive positioning that would (will) blossom (well beyond a herd of rhinos, I suspect), as more and more patients begin self-diagnosing and self-prescribing treatment.

If the cash-only model were more widely adopted by American physicians, I hope the outcomes would include the end of ludicrous bills and ridiculous “negotiated rates”. It makes too much sense to cut to the chase by taking the insurance company out of the process and making the cost of health care more transparent.

WRT “chronic disease” – the assumption that pains me is that most, if not all, can be avoided if the pt eats healthily, exercises, etc.

There are many chronic conditions that do not fit into the “eat healthy, exercise, quit smoking” category, such as allergies, asthma, mental illness, etc. People with this kind of chronic condition still get thrown under the bus without some mechanism for making prescriptions affordable. Even if those in this group were pretty vigilant about generic vs brand medications, there are not always acceptable substitutes.

John Bierma has some good comments regarding “futile care”. Unfortunately, it seems that cogent public discussion of this topic fuels the anti-reformers’ fire.

Actually that is EXACTLY who should be doing so. Ultimately we are all responsible for ourselves – the doctor is just an adviser. So, if you’re electrician says you should probably upgrade the wiring in your home – you can choose to ignore him, to get another opinion, or to research the matter. The same with your car, career, or child. The same with the lawyer who gives you advice. You are in control.

For myself I am in favor of having the option to negotiate directly with my providers directly for routine preventative care; as a person with small-company insurance it would definitely be preferable to the balance bill surprise. On the other hand, I would be concerned that this would drive people to neglect the sort of care that will prevent larger bills later on.

I also question how much these expenses really drive the overall problem. Intuitively, healthy people with inappropriate allergy meds sure seems like small potatoes compared to inappropriate ER utilization, insurance company overhead, and so on, but I certainly haven’t seen numbers. Has the author of this piece?

So an insurance company, knowing that I will probably spend more than $5000 in a year for medical expenses, is going to give me an affordable premium? How many “less” chronically ill are they going to recruit to offset what I use? Won’t they increase the premiums? Why would anyone buy an expensive supplemental policy for a chronic disease when paying the premiums is more than what they would pay out of pocket for those services? What about those who need more care than I? Are my premiums going to be even higher?

While I agree with most of the points made in the article, I see that there is no guarantee that decoupling the tax benefit for employer healthcare, and putting patients in charge of their health dollars will suddenly make them pay for the needed preventative care.

Therefore, these patients who choose less substantial health care plans which require less $ per mo, but more cash for services rendered, must be “forced” into getting the needed preventative care that they don’t want to spend out of pocket. People will only spend on something that they see as having value, and unfortunately, the benefits of preventative care are so delayed that most people won’t pay for them unless required.

I have blogged about why employer tax subsidies are an unfair subsidy to the wealthy: http://drbrenner.blogspot.com/2009/07/truth-about-controversy-surrounding_12.html

I personally think we should phase out the employer tax subsidies, require employers to give the same gross $ amounts in salary or in health care accounts so the employee only loses the tax break, not the gross dollar amount. Then everyone in the country is required to have a basic minimum of coverage: catastrophic plus standard preventative care for their age bracket (e.g. child ‘well-baby’ visits, and colonoscopies for those in their 40s). Everything else is out-of-pocket or requires a supplemental policy. Basic policies for most people will be inexpensive. Thus they can afford any cash outlays that are required. Chronic disease patients will have a low cost catastrophic plan, and a higher cost supplemental plan. Thus patients who are currently healthy have an impetus to stay that way so they never require these expensive high-cost supplemental plans.

And to help keep costs down on supplemental plans, pts will be encouraged through premium rebates, to be “healthy” chronic disease pts (e.g. Diabetics that keep the HBA1C in a normal range get a discount, participating in age/medical problem appropriate exercise programs get you a discount).

Hospital costs and expensive testing are the big ticket items in insurance anyway. So the risk pool won’t be destroyed by young people moving to catastrophic plans since the whole population will all be have these plans. If you simply have a choice of catastrophic vs comprehensive, young healthy people choose the cheaper catastrophic plan and less healthy, or chronic disease pts choose comprehensive therefore destroying the risk pool.

My suggestion above allows both to coexist without a destruction of the risk pool, while allowing people to actually know what they spend.