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rant

Must-read on health care

If you care about the U.S. government's budget deficit...
If you care about the competitiveness of U.S. businesses...
If you care about economic fairness...
If you care about preventing individual bankruptcies...
If you care about health care for all...

you must read Steven Brill's detailed exploration of the costs of the U.S. health care system.

If you already know how incredibly inefficient and corrupt the system is, read the article anyway: it's even more inefficient and corrupt than you thought.

Comments

This is sickening. I can add credence to his contentions with this anecdote: Someone I know was in Japan a few years ago and had a transient ischemic event. Turned out not to be serious, but it has very similar symptoms to a stroke. Her entire hospital costs (emergency room in Japan) including an MRI, came to a few hundred dollars. Compare that to costs in the US.

a similar anecdote

I spent a year in Winnipeg, Canada. On my last day, as I was packing boxes, I cut my finger open with a tape gun, exposing bone. My landlord (who conveniently lived next door) took me to the E.R., where I was asked my SIN (Canadian equivalent of SSN); I had one, but hadn't memorized it, so they looked it up by name and birthdate. An hour later I was out the door with three stitches in my finger, and nobody had asked for money. It probably cost the Canadian taxpayer a hundred bucks or so.

By contrast, the three or four times I've been to an E.R. in the U.S., it's taken at least two hours to even see a doctor, and at least six hours to get out the door, and the final itemized bill was in the thousands -- of which my insurance company paid a few hundred, and the rest was fiction.

Edited at 2013-03-03 12:23 pm (UTC)
I'm trying to figure out how much of it is false.

That business about "Medicare can't tell doctors to use the cheaper medication"?

http://www.medicare.gov/Pubs/pdf/11136.pdf

Here's a random Medicare Part D formulary which indicates which medications are which "tier" -- "preferred generic", "preferred brand", and "non-preferred" -- illustrating that Medicare is already telling doctors which medications to prescribe. It does not forbid them from prescribing non-preferred medications -- that would be a death sentence for some patients -- but it does have a variety of hoops to jump through to get to do so.

Perhaps there is something here I am not understanding, but it sure looks from here like an alarming and impassioned plea that "Medicare" be able to entirely forbid doctors from prescribing certain medications on the basis of comparative efficacy studies.

And with that in mind, I am guessing that by "Medicare" he actually means "payer", i.e. insurance companies.

That bit about how providers billing Medicare seem to be doing fine, and it's not like they are refusing to take Medicare patients?

Google "Medicare Optout".

There's other stuff that I know is hinky in there, such as the bit about RACs.

Certainly what he has to say is all very upsetting -- I've written about some of the same stuff myself -- but my spider sense in tingling.
Thanks for that information.

On the "comparative efficacy" thing, I think he was talking about drugs given in a hospital, not drugs prescribed for patients to buy at a pharmacy under Part D. Which, in a rational world, shouldn't make a difference, but they're different chapters of the Medicare law (right?). Even if so, it's a distinction he should have made clearer.

I suspect that "providers billing Medicare seem to be doing fine" is true as long as they don't have too large a proportion of Medicare patients. They keep accepting Medicare patients because the volume and relatively quick, predictable reimbursement make up for the lower rates -- like a money manager including some low-risk, low-yield investments in the portfolio. (But you're in a better position than I to answer that.)

Still, in a rational world, Medicare, Medicaid, private insurers, and the uninsured (assuming all of these still existed) would all pay roughly the same price for the same drug, test, or service -- certainly not orders of magnitude higher for the people least able to pay. And that price would be public knowledge, just like prices from Amazon or Home Depot or the corner grocery. If that price needed to be a bit higher than Medicare is currently paying, I think we could all live with that.


Edited at 2013-03-03 12:27 pm (UTC)
but they're different chapters of the Medicare law (right?)

No idea. If opportunity presents to interrogate one of our (or really any) psychiatrist or other party in the know, I will.

I suspect that "providers billing Medicare seem to be doing fine" is true as long as they don't have too large a proportion of Medicare patients.

Or you can otherwise make the books balance. I've been thinking about making this a post in my journal, but the summary: there is an emergent phenomenon, here in MA at least, resulting from details of medical licensure law intersecting with Medicare and Medicaid regulations and their low compensation rates. The practical upshot is we are winding up with two tiers of mental health care: poor people treatment and rich people treatment. Poor people treatment is conducted by the most junior possible clinicians (basically grad student and post-grad therapists, who have to do residencies to get licensed, and can be coerced into working for what amounts to ~$10-$20/hr), in ever larger institutions/agencies (impersonal and with awful bureaucratic impingements on care). Rich people treatment is conducted by senior clinicians in private practice.

Apparently, it's not just mental health? I have a patient on disability, who told me that she's had to get a new PCP three times in a decade, because each one quit after three years, and the clinic she was at assigned her someone else; apparently she is getting residents, and when they complete their residencies, they're off to jobs that pay actual MD money. So much for developing a long-term ongoing relationship with a treater. But she's on Medicaid; when she looks around for alternatives, they're all clinics like the one she's been at.

For that matter, I have a Medicare patient I've been seeing for about three years. She's been at this clinic for 9 years; I'm her fourth therapist. About 2 months after her third anniversary with me, she, out of the blue, asked me if I was going to be leaving, too. I assured her that I intended to continue working at the clinic and seeing her and my other present patients, but that I wasn't taking new ones.

What I did not trouble her by explaining was that, if a patient over 65 presents at my private practice, I will be forced to file my Medicare optout to accept that patient... which may make me ineligible to be her therapist at the clinic. Not sure, and it would probably involve lawyers, and maybe they wouldn't even be able to tell. Medicare rules about optout are very all-or-nothing, and if I decline to accept Medicare in my private practice, it may make me ineligible to be employed at any facility that accepts Medicare. (Well, or to see Medicare patients if I am so employed; but who would employ a clinician who was blackballed from a major insurer?) You see the sorting effect. But I digress.

Poor-people care is profitable solely because it's made up in volume on the backs of indentured labor paid vastly less than market rates, and who flee as soon as their indenture is up.

There's more sorting pressures, but I'll leave it there or I'll wind up writing the whole post as a comment in your journal. :)

[continued]
if I decline to accept Medicare in my private practice, it may make me ineligible to be employed at any facility that accepts Medicare.


In the comments section of some article or blog I read today was a doctor who says he doesn't take Medicare at his private practice, but does see Medicare patients at the hospital. Or maybe it was Medicaid. I don't know what state he lived in, IANAL, etc. etc.
If it is Medicare, maybe he just hasn't been caught yet. :(

I don't think Medicaid cares.

It is strange how different the two are.
[continued]

Still, in a rational world, Medicare, Medicaid, private insurers, and the uninsured (assuming all of these still existed) would all pay roughly the same price for the same drug, test, or service -- certainly not orders of magnitude higher for the people least able to pay. And that price would be public knowledge, just like prices from Amazon or Home Depot or the corner grocery.

Yes, a thousand times yes.

Also, I have no trouble believing about the triple billing thing: that was a pernicious AntiPattern in utility companies that I learned about on my temp job with the Massachusetts regulatory body charged with overseeing them, the Comm of MA's Department of Public Utilities. Part of why they got a temp was they were stretched a little thin on staffing while putting together a conference for MA electrical companies (mandatory attendance) at which it was explained to electric companies that you may only charge for an electron once. Case example (real examples, details as best I remember from 1995): A condo complex is under development and the developer's lawyer handles the utility bills for it; units sell, somebody forgets to handle the change over in the electrical bills to the new owners, who think electric is included in their condo fee; after two years, the law firm, which handles a large number of accounts payable on a large number of properties, finally notices, "Hey, why are we paying this bill?" and contacts the electrical company; the utility replies, "How is it our problem you failed to terminate service when you no longer wanted to pay for it? We're not giving you your money back, and you have no legal grounds to ask for it back, but we're happy to terminate service going forward," and then turns around and presents the condo owners with two year back bills.

Back to health care, in related news: providers have no idea what they're getting paid, either, when there's an insurance company involved.

This resulted, which you may find interesting.
I was at the dentist last week and asked how much I owed on the previous visit. The receptionist explained that, after six months, the insurance company hadn't reimbursed them yet, nor even told them how much it would be. But her mother happened to have the same insurer I do, so she had a bootleg copy of the reimbursement schedule, which she could use to guess what I owed.

Helluva way to run a railroad....

This FAIR thing sounds cool. But the first search I tried on the "consumer" section of the site produced a page of SQL error messages, and the next one (for the rare, obscure word "orthodontia") produced no results. Needs some work on the implementation side.
Oh dear. Try a different browser? It was working great for me.