A Doctor Speaks on Health Care

Prescription RX

Scott Payne has a really insightful interview with physician Dan Summers that’s definitely worth reading for another perspective on how our current, awful system of health care works. Here’s a snippet:

As someone who works within the system on a day-to-day basis, what are your thoughts about the current state of health care in the US?

I think the current state of US health care is precarious.

For many people, it seems to be working just fine. For many other people, they think that it’s working just fine until they come upon some kind of significant health care expense. Suddenly, the insurance they thought was so good is revealed to be riddled with exceptions and inscrutable processes, and care they had thought would be covered is not. We’re often left in the unenviable position of recommending or ordering care that is simply out of reach for patients, even if they are insured and have been paying premiums for years.

Then there are families who have lost jobs, which is a significant problem in an economically depressed state like Maine. I can’t tell you how many times I have had patients who have been taking medication for years that they suddenly can no longer afford because a parent has lost the job that provided the insurance that paid for it. It’s immensely frustrating.

There are others whose employers don’t provide insurance, and who make too much for public insurance but not enough to afford to purchase a private plan. Even the costs of routine childhood preventive care can be daunting if you’re faced with paying them all out of pocket.

There is, of course, a flip side, which is that people often come in seeking expensive tests or medications that they don’t need, and people who are on public insurance (and thus incur no health care costs out of pocket at all) who come in repeatedly for frivolous reasons, or who treat the ER as an urgent care clinic because they don’t care to wait for an appointment in the morning, so even an unrepentant bleeding heart like me is given pause from time to time.

Just read the whole thing.

(cross-posted to Heretical Ideas)

FILED UNDER: Health Care
Alex Knapp
About Alex Knapp
Alex Knapp is Associate Editor at Forbes for science and games. He was a longtime blogger elsewhere before joining the OTB team in June 2005 and contributed some 700 posts through January 2013. Follow him on Twitter @TheAlexKnapp.

Comments

  1. TangoMan says:

    OK, I read the whole thing. It’s interesting getting one physician’s perspective where he mixes his on-the-ground knowledge with his ideological perspective and throws in a dash of ignorance on a few topics.

    Is this going to be a series? That might be a good idea. Get an insurance fraud investigator to give a perspective, get a medicare billing clerk to give their perspective, get a nurse to give her view, get a lab technician to opine, get a misanthrope to chime in, that is if he cares enough to bestow his wisdom on people, etc.

    Seriously though, he doesn’t talk at all about a host of issues that are important to health care reform. Some of his points, when they are anchored in experiential knowledge are worth reading, but I could do without his pollyannaish statements, to wit:

    At the end of the day, I care about health care reform because I don’t want my patients or their parents to have to decide between accessing care they need and having money to pay for the other necessities of life.

    OK, let him step forward and advocate that physicians take a 50% paycut and use those savings to fund more care for the patients that might have to do without other necessities in life. Money doesn’t grow on trees, so for the patient that gets free medical care another person, likely a stranger to the patient, has to suffer. The trade-off doesn’t appear so straighforward to me. I can come up with plenty of solutions so long as I can force the payments onto other people.

    This physician gives us his personal opinion, an opinion anchored in experience and ideology and self-interest. There are other physicians who likely match his experience but filter that experience through a different ideological lens and whose self-interest takes a different form. His commentary doesn’t add anything new to my view of the topic but perhaps others will find his experiential perspective gives them new insights.

  2. G.A.Phillips says:

    get a misanthrope to chime in, that is if he cares enough to bestow his wisdom on people,

    🙂

    Then there are families who have lost jobs

    Whole? This would be something about Obama that I could believe.

    I’m actually starting to believe that one Day heath care will be free. When Darthme destroys all the jobs the doctors and nurses won’t have any thing better do.

  3. just me says:

    I think they fail to address two key areas of healthcare expense at all.

    One that I think would be interesting to hear about is how many MD’s are produced each year by plan. Medical schools restrict the number MD’s so that there is a shortage.

    The lack of MD’s going into primary care positions rather than specialties.

    The lack of MD’s in underserved and rural areas (having insurance is no guarantee that you will be able to access a doctor easily or in a timely manner).

    And the big one for me-the connection of insurance to employment. There is a reason losing your job is financially devastating-you aren’t just losing your paycheck, but your medical insurance.

    Oh, and the doctor’s point about medical research in the UK-partly why researching in a country where medical is government controlled still leaves them the US market to market their innovations in. If the US market is limited, then I do wonder how new innovations can be marketed in a way that they are able to recoup the costs of the research.

    I read an article a few years ago about a woman in the UK who had cancer and was unable to access a new cancer drug developed by a company in the UK-because the UK would not market the drug at all due to its expense.

  4. odograph says:

    The Doctor opens exactly as many of us here have done:

    For many people, it seems to be working just fine. For many other people, they think that it’s working just fine until they come upon some kind of significant health care expense. Suddenly, the insurance they thought was so good is revealed to be riddled with exceptions and inscrutable processes, and care they had thought would be covered is not. We’re often left in the unenviable position of recommending or ordering care that is simply out of reach for patients, even if they are insured and have been paying premiums for years.

    The fact that our suspicions are confirmed by someone working in the field has no effect on the TangoMen of the world.

    They have the classic politics of “alternate reality.”

  5. Ponies. When do we all get ponies?

    As I understand Alex’s position it seems to be that clearly the current system isn’t perfect, so anything proposed by Obama will be better.

  6. Alex Knapp says:

    Charles,

    The two things that make Obama’s plan superior to the status quo are:

    – no more denial of claims for pre-existing conditions

    – mandating community ratings and rates for individual purchasers of health insurance

    The current system sucks. Obama’s plan is a slight improvement, but that slight improvement will mean that people will be able to afford health care who could not before and therefore fewer people will die or have serious health problems.

    Given that the costs of health care mean that care for serious conditions are often far beyond the reach of the average person (an average week’s stay in a hospital, for example, is a higher cost than the median annual income in the United States) that I think there is a role for government to step in.

  7. Steve Verdon says:

    Alex,

    That’s nice, but when do we get the ponies?

    Really, the big issue is money. It would be great if all it took was to expand coverage and reform insurance practices to stop the bad stuff, but that wont cut it. In fact, it will probably move forward the date when we drive over the cliff.

    Then your two improvements will go right through the windshield as the car slams into the ground at the bottom of the cliff.

    If you don’t address the money all the other stuff just wont matter or will make the situation worse. Its a foolish position.

  8. Alex Knapp says:

    Steve,

    The United States ranks highest in health care expenditures and last in outcomes among industrialized nations. Surely there are savings to be had. I think one thing of benefit would be some price and coverage transparency. My PCP, in an office of one doctor and one N.P. employes three, full-time workers whose sole job it is to handle payments from insurance companies.

    I’m pretty sure that could be streamlined to a signficant savings.

  9. Drew says:

    Please, Alex, stop the aggregate, and misleading, stats stuff. “Outcomes,” as currently defined, is a poor measure. Our health care system is simply superlative.

    Look, could we not all agree on a few simple concepts?

    1. If people, in good faith, pay their premiums over time (or their employer does) they should not be rooked out of coverage when the need arises?

    2. We need to either ween ourselves off of employer based coverage – or find a way to portability – and rid ourselves of a hideous unintended consequence of boneheaded government policy from the Roosevelt era? Oh, those government policies.

    3. Insurance needs to be insurance, not cover evrything health maintenance. That’s just plain dumb, and unsustainable economically.

    4. There has to be a way to make amends for covering pre-existing conditions. The current problem stems from lack of portability, or individuals irresponsibility. But there certainly should be a way – admittedly with high premiums – to create risk pools for people with pre-existing conditions. After all, they don’t all suffer worst outcomes.

  10. Steve Verdon says:

    Alex,

    You want to do extra things for health care, but at the same time we can’t afford the broken system we have. You don’t see a fundamental problem with this position? Its just irresponsible, that is all there is to it.

    Its like saying, I need to roof my house, add on a spare bedroom, and increase my general household expenditures another couple of percentage points so total spending grows at 8% while my household income grows at 2.5% to 3%.

    Maybe you can do it for awhile if you are rich, but only awhile. After that your f*cked.

    If you want to do these things you find desirable, and they are desirable, then you need to find the savings. I’m all for improving health care and saving money. But we have to do both. Anything else is just foolhardy.

    I’m pretty sure that could be streamlined to a signficant savings.

    I’ll believe it when I see it. Point me to the legislation that has support that does this.

  11. TangoMan says:

    But there certainly should be a way – admittedly with high premiums – to create risk pools for people with pre-existing conditions. After all, they don’t all suffer worst outcomes.

    I have a solution! Consider these facts:

    1.) Democrats want to force insurance coverage on everyone;
    2.) Democrats want to migrate everyone into a single payer system;
    3.) Democrats want to ignore the issues of pre-existing conditions;
    4.) Democrats, if they could have their way, would cover illegals.

    The debate has recently introduced the “compromise” of co-ops.

    All that our betters in government need do is create a new Democrat Health Co-op. Every person across the nation who is registered to vote as a Democrat would be compelled to migrate into the coop (points 1 & 2) and every person with pre-existing conditions would be welcomed into the co-op with loving and open arms (point 3) and illegals could have their health and self-esteem improved by being forced into this new Democratic Health Co-op (point 4).

    All non-Democrats could continue with their existing plans, they could exercise their choice, they could minimize the redistribution that they so disfavor.

    Polls regularly show that 20% or so of the nation views themselves as liberals, so in a nation of 300 million people we’d be looking at a membership of 60 million people in the Democratic Health Co-op, creating a behemoth that is twice as large as the entire nation of Canada and would cover about the same number of people that are covered in the French or British systems. Within this co-op they can redistribute income to their heart’s content, they can cover every person with pre-existing conditions, thus earning their gratitude, and they can live true to their political principles. The bottom line is that there is nothing stopping liberals from living true to their principles, and in fact, the need to force their political opponents to live by liberal principles shouldn’t be a reason to deny themselves the joy of living true to liberal principles – full speed ahead to income redistribution but only within the ranks of liberals, full speed ahead on mandating coverage, but only for liberals, etc. Why deny yourselves heaven on earth by waiting for conservative to embrace your principles. Don’t put yourselves out by waiting for us. Go ahead, jump.

  12. Alex Knapp says:

    Drew,

    Our health care system is simply superlative.

    Agreed. If you can afford it. My point is that the United States spends the most money on health care, but doesn’t see signficantly better outcomes than any other industrialized country and on many measures is worse. This leads me to believe that it is within the realm of possiblity that we can cut costs signficantly without affecting the quality of care.

    1. If people, in good faith, pay their premiums over time (or their employer does) they should not be rooked out of coverage when the need arises?

    2. We need to either ween ourselves off of employer based coverage – or find a way to portability – and rid ourselves of a hideous unintended consequence of boneheaded government policy from the Roosevelt era? Oh, those government policies.

    Agreed on both.

    3. Insurance needs to be insurance, not cover evrything health maintenance. That’s just plain dumb, and unsustainable economically.

    I think you create some perverse incentives here, leading to higher health costs than are necessary.

    To give a not-too-uncommon example, take a family of four — median income in the United States for a family of four is about $48,000. Let’s say they each get a physical. Around here, a doctor’s visit is $140 a pop, but I’ll be generous and just go $100. That’s $400 bucks just for the physicals. Now they make their recommended twice-yearly trip to the dentist. That’s $800. And don’t forget the eye doctor. That’s another $400.

    So, assuming that they need no dental care, no prescriptions, no glasses, have no broken arms or tonsillectomies, you’re talking “maintenance” expenses of $1600 / year. That’s about 3-1/3% of your income right there. Now, we can’t forget the insurance premiums, right? When I was a single guy in my 20s five years ago, my out-of-pocket monthly premium (and my employer paid for part) for catastophic coverage ($5,000 deductible) was about $120 a month. Let’s be generous and say that for a family of four, that out-of-pocket cost is $300 (it’s likely higher, but I’m being simple here).

    So, assuming that every does their routine health maintenance and pays their premiums, you’re looking at an annual expenditure of $5200 / year — about 10.8% of income. Of course, that’s assuming zero taxes, but you can’t assume that. So now let’s go with a 15% effective tax rate on the 48000 for state/local/federal taxes (it’s probably higher, but again, this is an illustration). So the income is really 40,800, and suddenly that $5200 / year is almost 14% of your income.

    Now, all of that is bearable, right?

    But then let’s say Dad gets a twinge in his chest and he’s a little short of breath. Now, with a co-pay of $20, he might be willing to go to the doctor for a “just in case” look. But if he has to front the whole $140… well, maybe it’s just heartburn. And besides, he doesn’t want to take two hours off his workday, because that’s more money out of pocket so… forget it.

    In scenario A, the $20 co-pay, dad goes to the doctor, doctor gives him medicine for his cholesterol, things are fine–just a $4 co-pay per month for the medicine. In scenario B, where Dad has to pay $140, he puts it off and has a heart attack. And what was a small cost for prescription is suddenly a $100,000 hospital stay.

    It seems to me that it’s not too unworthwhile to have maintenance costs (doctor’s vistits, prescrptions) be essentially free (or a small co-pay to discourage free-riderism), because it’s simply more cost-effective, both in terms of money and in quality of life.

    4. There has to be a way to make amends for covering pre-existing conditions. The current problem stems from lack of portability, or individuals irresponsibility. But there certainly should be a way – admittedly with high premiums – to create risk pools for people with pre-existing conditions. After all, they don’t all suffer worst outcomes.

    Yes, we need to cover them, but let’s be careful about premiums. What if the high-premiums effectively price some people out of market? After all, chronic illnesses aren’t exactly condusive to high-paid employement…

  13. TangoMan says:

    My point is that the United States spends the most money on health care, but doesn’t see signficantly better outcomes than any other industrialized country and on many measures is worse.

    Similarly, arranged marriages produce better outcomes than love-based marriages, when the metrics are length of marriage, children produced in marriage, stay at homes moms raising children, etc. When you exclude metrics like degree of communication, feelings of love, satisfaction with one’s mate, survival rates after treatment, rates of proceeding with treatment earlier, rather than later, in a disease cycle, etc, then you open yourself to clinging to a false understanding. Similarly, when you don’t account for suffering from waiting, disease progressing from denial of treatment because severity of symptoms are not sufficient to order diagnostic tests, etc, then you don’t really capture the whole picture.

  14. TangoMan says:

    This physician was writing about the situation in Maine, and wouldn’t you know it, today the Wall Street Journal publishes this report on Maine’s move to universal health care:

    In 2003, the state to great fanfare enacted its own version of universal health care. Democratic Governor John Baldacci signed the plan into law with a bevy of familiar promises. By 2009, it would cover all of Maine’s approximately 128,000 uninsured citizens. System-wide controls on hospital and physician costs would hold down insurance premiums. There would be no tax increases. The program was going to provide insurance for everyone and save businesses and patients money at the same time.

    After five years, fiscal realities as brutal as the waves that crash along Maine’s famous coastline have hit the insurance plan. The system that was supposed to save money has cost taxpayers $155 million and is still rising. . . .

    This problem was exacerbated because since the early 1990s Maine has required insurers to adhere to community rating and guaranteed issue, which requires that insurers cover anyone who applies, regardless of their health condition and at a uniform premium. These rules—which are in the Obama plan—have relentlessly driven up insurance costs in Maine, especially for healthy people.

    The Maine Heritage Policy Center, which has tracked the plan closely, points out that largely because of these insurance rules, a healthy male in Maine who is 30 and single pays a monthly premium of $762 in the individual market; next door in New Hampshire he pays $222 a month. The Granite State doesn’t have community rating and guaranteed issue. . . .

    Last year, DirigoCare was so desperate for cash that the legislature broke its original promise of no tax hikes and proposed an infusion of funds through a beer, wine and soda tax, similar to what has been floated to pay for the Obama plan. Maine voters rejected these taxes by two to one. Then this year the legislature passed a 2% tax on paid health insurance claims. Taxing paid insurance claims sounds a tad churlish, but the previous funding formula was so complicated that it was costing the state $1 million a year in lawsuits.

    Unlike the federal government, Maine has a balanced budget requirement. So out of fiscal necessity, the state has now capped the enrollment in the program and allowed no new entrants. Now there is a waiting list. DirigoChoice has become yet another expensive, failed experiment in government-run health care, alongside similar fiascoes in Massachusetts and Tennessee.

  15. just me says:

    3. Insurance needs to be insurance, not cover evrything health maintenance. That’s just plain dumb, and unsustainable economically.

    I agree with this. I think the idea that insurance should cover everything at minimal to no cost to the insured is part of the problem with cost. When it feels free, you tend to use it as if it was free.

    I don’t think this alone is going to fix the system, but I think it is an attitude problem.

    Even in Canada there are some types of healthcare that aren’t covered by the government plan-drugs and certain types of doctors/providers.

    I really think the biggest problem with our healthcare system is its attachment to employment-and I think the best way to start fixing the system is to separate insurance from employment-but I am not so sure citizens are going to sign on that for anymore than they are ready to go out and have a US version of the NHS.

  16. steve says:

    “Similarly, when you don’t account for suffering from waiting, disease progressing from denial of treatment because severity of symptoms are not sufficient to order diagnostic tests, etc, then you don’t really capture the whole picture”

    Outcomes capture all of the above. That is why they are so useful. As a doc, I want answers right away. I have very little patience for waiting. However, there are times when it really does not matter if I wait a little longer. Sometimes I get better data by waiting longer. If disease is progressing, as you posit, because diagnostic studies are delayed, it will show up in worse outcomes. If you are not seeing worse outcomes, then waiting did not matter.

    This is pretty important to understand if you are going to follow medical data. The literature has many instances of new medications which were better at controlling blood pressure, joint pain, blood glucose, etc., but when you looked at overall outcomes you found higher mortality rates. Ignoring outcomes and just declaring ourselves superlative, or any given treatment superlative is a bad idea. You need data to support assertions.

    If we want to make wait times our most important metric we can, just as long as we understand that it costs more to do so and does not guarantee better outcomes. Shorter wait times may simply reveal a system with over capacity or one that emphasizes speed over thoroughness. Often it just signifies a different approach. We treat prostate cancer very early. Much of the rest of the world treats it later. Patients in both groups live to about the same age on average. Which is better?

    Steve

  17. Steve Verdon says:

    I think you create some perverse incentives here, leading to higher health costs than are necessary.

    To give a not-too-uncommon example, take a family of four — median income in the United States for a family of four is about $48,000. Let’s say they each get a physical. Around here, a doctor’s visit is $140 a pop, but I’ll be generous and just go $100. That’s $400 bucks just for the physicals. Now they make their recommended twice-yearly trip to the dentist. That’s $800. And don’t forget the eye doctor. That’s another $400.

    So, assuming that they need no dental care, no prescriptions, no glasses, have no broken arms or tonsillectomies, you’re talking “maintenance” expenses of $1600 / year. That’s about 3-1/3% of your income right there. Now, we can’t forget the insurance premiums, right? When I was a single guy in my 20s five years ago, my out-of-pocket monthly premium (and my employer paid for part) for catastophic coverage ($5,000 deductible) was about $120 a month. Let’s be generous and say that for a family of four, that out-of-pocket cost is $300 (it’s likely higher, but I’m being simple here).

    So, assuming that every does their routine health maintenance and pays their premiums, you’re looking at an annual expenditure of $5200 / year — about 10.8% of income. Of course, that’s assuming zero taxes, but you can’t assume that. So now let’s go with a 15% effective tax rate on the 48000 for state/local/federal taxes (it’s probably higher, but again, this is an illustration). So the income is really 40,800, and suddenly that $5200 / year is almost 14% of your income.

    Now, all of that is bearable, right?

    But then let’s say Dad gets a twinge in his chest and he’s a little short of breath. Now, with a co-pay of $20, he might be willing to go to the doctor for a “just in case” look. But if he has to front the whole $140… well, maybe it’s just heartburn. And besides, he doesn’t want to take two hours off his workday, because that’s more money out of pocket so… forget it.

    I rest my case, you want to have your cake and eat it too.

    Yes, all of the above may very well be true, but at the same time the system we have and most other countries systems are unsustainable. The brutal reality is that people may very well have to start making decisions on using less resources, not more.

    Faster, better, cheaper….pick two.

  18. Steve Verdon says:

    It seems to me that it’s not too unworthwhile to have maintenance costs (doctor’s vistits, prescrptions) be essentially free (or a small co-pay to discourage free-riderism), because it’s simply more cost-effective, both in terms of money and in quality of life.

    Uhhhmmm maybe not.

    You have 1,000,000 of those dads. So you incur $140,000,000 for those just seeing the doctor (forget the tests and what not that might be done). If you don’t head off at least $140,000,000 in costs (probably more if we throw in additional tests) by early detection then you have actually lost money, not saved money.

    Sure at an individual level the prevention can look realy good both in terms of extending life and saving money, but for the population as a whole it could very well be a money loser.

    So making it “free” or “nearly free” is not going to be a great idea. Really, Grandma’s bormide of “an ounce of prevention is worth a pound of cure” needs to be checked against empirical data and for an entire population, not just her grandchildren.

  19. TangoMan says:

    Outcomes capture all of the above. That is why they are so useful. As a doc, I want answers right away. I have very little patience for waiting. However, there are times when it really does not matter if I wait a little longer. Sometimes I get better data by waiting longer. If disease is progressing, as you posit, because diagnostic studies are delayed, it will show up in worse outcomes. If you are not seeing worse outcomes, then waiting did not matter.

    It looks to me that you’re arguing just to be contrarian, for your “just so” examples don’t support your thesis that “Outcomes capture all of the above.” An test done early in the process, which compared to a test done later in the process, gives you data on rate. One test, done extremely late in the process just shows a static presentation. If timeliness doesn’t impact outcome, then you should be advocating mandatory delays for all procedures.

    Sometimes I get better data by waiting longer.

    Yeah, so? Sometimes you don’t. I don’t see how a more progressed disease state, which removes ambiguity from the diagnostic process, helps improve medical outcomes. The argument that it is preferable to allow a disease to progress unmonitored in order to remove ambiguity doesn’t convince me. I prefer that a disease be caught, or suspected, early, be monitored when there is ambiguity, and rate of progression be a part of the information that is included in the decision process.

    If you are not seeing worse outcomes, then waiting did not matter.

    We’re crossing wires on terminology. Worse outcomes as measured on which metrics? As I noted in my original comment, if certain metrics are not included then we can’t use data that arises from these non-measured metrics. Looking at life expectancy as a metric but not measuring survival rates from, let’s say, prostate cancer, means we lose information. So, in general, focusing on life expectancy shows that waiting doesn’t matter. Focusing on prostate cancer 5 year survival rates shows that waiting does matter.

  20. steve says:

    “An test done early in the process, which compared to a test done later in the process, gives you data on rate. One test, done extremely late in the process just shows a static presentation. If timeliness doesn’t impact outcome, then you should be advocating mandatory delays for all procedures.”

    I guess I was unclear. It is not the diagnostic part so much as the treatment. We diagnose prostate cancer at 50. France diagnoses at 50. We treat right away. France generally waits unless they meet specific criteria as prostate is a slow grower as a rule. Both sets of patients end up dying at about the same time, but when you do the statistics it looks as though the survival rates, 5 year survival, 15 year survival, etc. are better for the US, but if you looked at 5 year survival from the date of diagnosis, they will be very close.

    I would not advocate for delayed testing or treatment as a general rule, but rather timely appropriate diagnosis and treatment. This should be monitored by outcome data. The U.S. model of early treatment means more will die from treatment complications. The European model means more will die from disease progression missed. They appear to equal out.

    Unbundling each part of the diagnostic process or treatment for any given disease is often a useful research tool. In the end, though, what we care about is whether the patient is better. You are concentrating on waiting times, while I concentrate on outcome. If the outcomes are equal, then the waiting time did not matter.

    Steve

  21. TangoMan says:

    It is not the diagnostic part so much as the treatment.

    (Look, I know that I’m spelling out the obvious to you, but our conversation isn’t restricted to just the two of us, so I’m hoping that some can find some value to my points. Further, from my reading of your comments I don’t see the following points addressed so I’m assuming that they are unstated premises which are not percolating up into your argument and thus the dialog is furthered by bringing them into full display.)

    Diagnosis helps determine treatment. Treatment varies depending on stage of disease, complications that arise (e.g. metastasis), severity, etc.

    A lumpectomy, for a breast cancer that is caught early compared to a modified radical mastectomy for a progressed breast cancer might yield the same outcome – the woman’s life is saved and the 5 year survival rate might be identical (for sake of argument) and if that is the metric used then the two procedures deliver the same outcome and we can conclude that there is no harm in delaying cancer screening. However, once you measure women’s reactions to the two alternatives you introduce a new metric and we can discern that there is a significant downside to a woman who must undergo a modified radical mastectomy.

    I would not advocate for delayed testing or treatment as a general rule, but rather timely appropriate diagnosis and treatment. This should be monitored by outcome data. The U.S. model of early treatment means more will die from treatment complications. The European model means more will die from disease progression missed. They appear to equal out.

    I agree with this analysis from a global perspective. My disagreement arises from denying agency to patients. Denying early treatment, even with risk factors explained to the patient, removes from the patient the control over their body. Some people might feel “control over medical treatment” is a metric that is just as important as the metric of life expectancy.

    Unbundling each part of the diagnostic process or treatment for any given disease is often a useful research tool.

    I agree. Purposeful attempts to not seek information or the loss of information through reliance on generality instead of specificity in decision making is not what I consider to be the preferred standard.

    In the end, though, what we care about is whether the patient is better.

    Sure, but first define better. A woman who could have survived with a lumpectomy but must instead undergo a modified radical mastectomy probably doesn’t believe that she is “better” full stop. She can accept that she is better off than being dead but she would likely argue that she would have been better off having only a portion of her breast removed rather than losing her entire breast and lymph nodes.

    You are concentrating on waiting times, while I concentrate on outcome.

    Actually, I’m not, I’m just using wait times as an example of a standard that is ignored. There is utility associated with decreased wait times. If an ailment is impairing, then the remediation of the ailment reduces impairment (in a simple model) and thus a benefit is delivered. That benefit is also an outcome, it’s just not the generalized outcome, such as life vs. death, years added to life, that I believe you mean when you reference the concept of outcome.

    If the outcomes are equal, then the waiting time did not matter.

    When all else is equal, I agree. A physician who immediately treats a patient for a common cold delivers the same outcome as is seen in a patient with a cold who has to wait two weeks to see a physician for his common cold. The outcomes are the same, so speedy treatment is irrelevant.

  22. An Interested Party says:

    4.) Democrats, if they could have their way, would cover illegals.

    Where is the proof this claim…

  23. An Interested Party says:

    *of this claim…

  24. oh4real says:

    @TangoMan: Thanks for copy/pasting the WSJ Maine story.

    Without knowing much more than what you copied, a few thoughts struck me:

    1) Question everything:
    The WSJ quoting a think-tank on insurance premiums in Maine vs. NH needed to do their homework. I went to ehealthinsurance.com and found a large range of temporary health insurance plans for single males that cost $50-$300/mo in Maine. That $762/mo quote conveniently proves their point, but it is highly dubious.

    2) Subsidies are not the answer:
    The Maine experience may indicate that preventing for-profit insurance firms from excluding pre-existers and denying renewal to just-got-sickers without offering a publicly capitalized, non-profit plan is doomed to failure. Dirigo offered a publicly subsidized, for-profit private plan – where anyone who can’t afford it gets state subsidies. I think it’s the subsidies that are forcing the Leg to increase taxes.

    3) If it walks, talks and quacks, it’s probably a duck:
    Health insurers are notorious for spending time/money on PR spinning of their policies. They also generally collude by virtue of their state-by-state oligopolies (1-3 insurers with >80% of customers). They are clever and can be very strategic at playing “the game” of public policy/opinion.

    That being said, who’s to say that the insurance oligopoly in Maine is not purposefully driving up health care costs in order to break the will and the back of the Govt? Knowing that (a) Maine can’t run a deficit, (b) Maine will be forced to raise taxes to pay for subsidies, (c) locals will revolt at tax increases, then it is not unreasonable to conclude that the insurers purposefully and strategically drive premiums up to backdoor a rewrite/repeal of the Dirigo Act.

    Bottomline to me:
    The Maine situation reinforces my opinion that you can’t force for-profit companies to assume the liabilities of hihg-cost customers (in this case, the sickos), while simultaneously expecting them to reduce premiums to the insured.

    We must include a publicly-capitalized, non-profit plan (aka “AmeriCare”) as competition to privately-capitalized, for-profit orgs which historically do not self-regulate or pass cost-savings to customers (they pass them to sr. mgmt or shareholders as dividends).

    If, in the end, AmeriCare has controlled costs, reduced premiums and comparable coverage/delivery/quality with consumers flocking to it, then the ever-creative private firms can either innovate their way to compete as insurers, change from ‘insurers’ to AmeriCare patient administrators or close up shop.

    If, in the end, AmeriCare fails at it’s mission and has to keep dipping into the public coffers for funding (not capitalizing) [HR3200 – Sec.222.(a)(1)(B) & Sec. 222.(b)(2)(A)], then the private market wins.

    For the record: my reading of HR3200 is that AmeriCare must rely on premium payments for funding and create a trust/contingency fund during start-up($2B) and for surpluses. See Sec.222(b)(2)(C)

  25. TangoMan says:

    Where is the proof this claim…

    The Democrats rejection of two amendments which would have required proof of citizenship or legal residence. Let me explain it to you by way of analogy. If Congress passes a law that states every citizen, on September 1, is to go to a bank and pick up an entitlement of $200 cash but the banks are not allowed to ask for proof of citizen status, then how effective is the law at restricting the benefit only to citizens?

    More here:

    Title II, Subtitle C, Section 246 of the House health care bill (H.R. 3200) stipulates “no federal payment for undocumented aliens.” The Senate bill states that beneficiaries of federal health care programs must be a citizen or national or an alien lawfully admitted to the United States.

    But neither bill has a provision for verifying citizenship status, according to these experts.

    Rector said people signing up for government-run health care programs would not have to substantiate that they are in this country legally. “The health care reform legislation turns that on its back and tramples it into the dust,” Rector said. “It basically says, ‘We will not verify, we will not check, we have a complete open door for every illegal immigrant, current and in the future, to simply enroll and receive benefits under this program.’ . . .

    Edwards said two amendments proposed in the House to require verification of citizenship and other qualifications were voted down and that Senate legislation also lacks any kind of verification provision.

    “Congressman Dean Heller (R-Nev.) offered an amendment in the Ways and Means Committee to correct that, but it was defeated along party lines,” Edwards said. “Senate legislation omits the same eligibility verification requirements that would ensure that only lawful immigrants and U.S. citizens benefit under these programs.”

    Here is Congressman Heller’s statement:

    Today U.S. Congressman Dean Heller (R-NV) offered an amendment to the America’s Affordable Health Choices Act (H.R. 3200) during the House Ways and Means Committee markup that would require the use of existing citizenship verification tools to determine eligibility for taxpayer-funded healthcare benefits. The Heller amendment was defeated.

    Why would citizen verification amendments be voted down on party line votes? Seriously, what do Democrats find so objectionable about verifying eligibility?

    Secondly, the law as it stands today will still compel hospitals to treat every illegal who shows up asking for treatment, and this new legislation doesn’t address that injustice.

    Thirdly, President Obama has promised the illegal lobby that he will deliver Amnesty for illegals next year, so even if the forces of all that is good and righteous in the universe manage to prevail and citizenship verification is included in the health care bill, we still have to contend with the evil that is coming down the legislative pipeline.

  26. An Interested Party says:

    Secondly, the law as it stands today will still compel hospitals to treat every illegal who shows up asking for treatment, and this new legislation doesn’t address that injustice.

    So they should be turned away even if that would mean some would die? And should hospital emergency rooms also turn away people who can’t pay/don’t have insurance…

    And who knew that it was “evil” to grant amnesty to illegal immigrants…perhaps we should just round them all up and deport them…

  27. TangoMan says:

    And who knew that it was “evil” to grant amnesty to illegal immigrants…perhaps we should just round them all up and deport them…

    I’m glad that you’ve come over to the side of enlightenment. Welcome. The sooner the better right, because think of all the unemployed people who could then find new jobs.

    So they should be turned away even if that would mean some would die?

    If I run into a burning house I do so with full knowledge that I might die in that environment. Illegals who invade this nation have no legitimate claim on taxpayer provided health care. Now, if physicians and nurses want to set up a donation pool and use the proceeds of this pool to fulfill what they see as their moral and professional duty, then I don’t mind that they provide health care to illegals because that healthcare is being personally funded by them.

    Frankly, I don’t buy the notion that those who advocate for health coverage for illegals are more compassionate or more enlightened than those who oppose such measures, because spending other people’s money on such schemes in order to posture as being more caring doesn’t, in fact, make one more caring. Anyone who feels strongly about this can stop at any hospital and just write them a blank check and instruct that the hospital fill in the amount after they treat an illegal. That type of person would truly be a caring person.

    And should hospital emergency rooms also turn away people who can’t pay/don’t have insurance…

    We can come to a compromise position on this point so long as the patients are citizens or have legal authority to be in the US.

  28. An Interested Party says:

    I’m glad that you’ve come over to the side of enlightenment.

    Oh yes, that is such an “enlightened” viewpoint…it must frustrate you to want something that will never, ever happen…

  29. tubal reversal one of the best treatment process for those women who want to re-birth the child again after tubal ligation.