Healthcare Reform: What principles do you want congress and the president to abide by?

Diabetes Advocacy Public Advocacy
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This election, no matter how you view the results, has started a national dialog about healthcare. Healthcare is going to be discussed if President Elect Trump has his way. If there is to be a national discussion, what principles do you wish it to be based on? Please keep this discussion non political (if that is possible). Discussion that come from the heart, not political rhetoric, is what is meaningful here.

Since this is my post I will get the ball rolling.

Healthcare should be universal, in saying that I mean that healthcare is a basic human right. I do not mean that government needs to be the direct payer of healthcare and I’m not saying it shouldn’t be but everyone one should be able to afford it.

Healthcare should cost the same for everyone no matter how its paid for. No one should be charged more or less just because they are on a different payment plan.

The government should stay the hell out of the exam room. Treatment decisions should be a product of sound medical principles not the decisions of bureaucrats. There is a well established system to educate and insure the competency of our medical professionals. If that system is inadequate improve the system.

Free market principles should be the mechanism that keeps cost in check. Forced cost savings have a tendency to stymie innovation. Forced savings tend to breed corruption. Whether we like it or not this is a free market country, let’s use that to our advantage.

Regulate as little as possible. Regulation only breeds bureaucracy. The are very few things that a bureaucrat can’t over complicate.

This one is bound to be controversial. Level the playing field when is comes to drug pricing. All developed nations should pay the cost of drug development. Other nations should not enjoy an advantage in cost nor should we.

I realize that not all are going to agree and that I have only scratched the surface.

The floor is open for discussion. Please keep it civil and on topic. Remember this is a discussion about principle, not approach. How it is accomplished is a different subject all together.

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  1. costs need to be controlled by creating a functional marketplace and ensuring there is legitimate profit-motivated competition. Under current models profit is only increased by raising costs. Under a functional and competitive model it would be achieved by offering more value per dollar than competitors. This would drive costs down instead of up. This applies across the spectrum of healthcare from doctor fees to prescription costs to medical devices to hospital fees etc.
  2. the people receiving the benefit of the goods and services need to (at least to some extent) need to be the ones paying for them-- this is to allow for valid and reasonable patient centered cost-benefit analysis-- which is not possible otherwise-- and is a prerequisite of a functioning market.
  3. preexisting conditions can not ever affect eligibility for any insurance coverage
  4. the vulnerable and truly incapable in our society need to be protected and cared for regardless of cost.
  5. insurance should be reserved for unforseeable major health problems. Routine and maintenance healthcare should be affordable without a third party payer (see #1 and 2.). Eg. There is no reason for a box of novolog to cost $400-- there’s no good reason for it to cost more than about $30.
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Return the practice of medicine to physicians by not allowing health insurers to dictate how often a physician can see a patient, what tests a physician can order, or which medications a physician chooses to prescribe. (As it now stands, health insurers control how medicine is practiced in the U.S. by limiting or outright disallowing visits, tests, and the majority of useful medications, among other things.)

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[quote=“Sam19, post:2, topic:57362, full:true”]
5) insurance should be reserved for unforseeable major health problems. Routine and maintenance healthcare should be affordable without a third party payer (see #1 and 2.). Eg. There is no reason for a box of novolog to cost $400-- there’s no good reason for it to cost more than about $30.
[/quote]This is, in my opinion, THE key issue that keeps us from ever coming to any kind of sensible “solution” to the health care “problem”.

We have developed a culture where we do not see health care as an ordinary, regular life expense, like food, shelter, clothing, transportation, etc. etc. etc.

Instead, we expect someone “else” to pay for it. But we demand it as a “right”.

In my view, health care is no more a right, nor is anyone entitled to it, any more than food. We expect people to provide for their own needs if they are able. We don’t have nationalized food distribution programs that all must participate in to get food.

No, we simply expect most people to feed themselves, and they do.

Why is health care any different?

I plan for health care expenses. I budget for them. Just as I do for food, gas, clothing, electricity, and everything else. I plan, budget, and pay for health care, just like food, before I spend $$ on dining out, big screen TVs, satellite TV, fine independent beers, etc.

The vast majority of people that whine about the cost of health care have actual health care tabs each year far below that which we diabetics have. They do not have a health care cost problem… they have an attitude problem.

My solution? Make health insurance actually insurance – designed to cover unanticipated expense due to catastrophe. Pay for routine health care expenses – a few thousand a year, tops, for most people – directly out of pocket. Most people never have any interaction with their insurer beyond simply paying their premiums, year in and year out, just like with auto insurance.

Imagine how much would be saved if every payment for everything didn’t have to be laundered through an insurance company.

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Imagine how much an oil change for your car would cost if Jiffy Lube was billing your auto insurance instead of competing for your cash business by offering the most value per dollar that they can. I don’t think we’d be seeing $20 oil changes for very long… I think we could soon add a zero to that, maybe two— and of course the rates for said insurance with such silliness would soon skyrocket.

Try this experiment-- Call an auto glass shop and inquire about the cost of a replacement windshield for your car. See if they ask you if it’s an “insurance job” and then do some wondering…

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Right on, RG!!

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Honestly, this conversation highlights to me why it’s so hard in the first place to implement any kind of health care system that people are happy with. Some people believe everyone should have access to health care, while others don’t. Some people believe the price should be uniform, I actually don’t know if I do, etc.
For me the main principles should be:

  1. We do not let people die on the street, or of easily preventable illnesses, because they cannot access medical care, no matter how “deserving” or not. I don’t believe any person is in a position to judge how deserving another person is very accurately, and I certainly think the market is abysmal at sorting this out. We have one of those Cadillac healthcare plans that allows us to easily access the best of medical care, but I know for sure we are no more “hardworking” or “deserving” of healthcare than the caregivers at my son’s daycare, many of whom have kids with serious medical conditions or loved ones suffering from terminal illnesses. Maybe this health care is very bare bones and based on only the most solid data, meaning that some people with some conditions will only have access to newer/more expensive drugs if they purchase supplemental private insurance. But I can’t stomach the idea of people skimping on their insulin because they can’t afford it.
  2. Price transparency. I think it should be law that you are allowed to call up a medical provider in advance, ask them how much something will cost, and have them give you an answer right away. I would be happy to “shop around” if I knew how much things cost, even for my insurer. This is basically impossible right now.
  3. Price negotiation. This should be an option as well that all doctors should be required to publicize. I explicitly do NOT believe that, say, a person earning 20k a year should have to pay the same $450 per visit that my endo receives for my visit. Even if I were paying out of pocket, I believe that would be unfair.
    *ETA: Also price estimate before care is rendered with the option of rejecting care based on its price (barring emergencies).
  4. I agree with people that routine medical care should be something that we pay for out of pocket to the extent we are able. I would rather pay for my annual, my checkup, etc. and pay less as my monthly health insurance premium. The issue is that, again, someone who earns 20k a year simply can’t pay for those checkups.
  5. Faster drug development and greater access to experimental drugs. I believe the FDA should have some mechanism that allows drugs that would currently be classified as Phase III to be approved on an experimental basis at a very low price with an automatic expiration if, in, say 2 years they do not provide data showing the efficacy of that drug/low side effects. In exchange, the drug companies can begin recouping costs on those drugs during the trial, but would be barred from doing any kind of promotion/advertising to the public, as the drug is experimental.
  6. Insurance should not be tied to your employer. Sorry, this is a weird market quirk that makes no sense to me.
  7. No ability to deny people based on pre-existing conditions, gender, or life-stage.

Honestly, I think something like single-payer plus the option of purchasing private insurance for specific types of treatments makes sense. I would love to not deal with insurance for the 90 percent of routine care we experience.

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I see a couple of problems:

  1. Price transparency.
    If a potential patient calls my office and asks how much it will cost to see me, we are not able to tell them this information because: a. I cannot predict exactly how long the appointment will take and I cannot predict the complexity of the issues before hand. Therefore I do not know which CPT Code(s) will be billed, which determines the charge for the appointment. b. Even after my office staff has verified a patient’s insurance coverage, there is really no way to know exactly what their copay will be, even though their insurer will say that the copay is ___% of the maximum allowable, because 9 times out of 10 it actually isn’t; the only way to know for sure is to go through at least one billing cycle.

  2. Price negotiation.
    What? I should charge someone who makes less money per year less than someone who makes more money per year? Do people who earn less pay less for the same loaf of bread at the supermarket than someone who makes more? Do my overhead costs (office lease, staff salaries, office supplies, malpractice insurance, medical society dues, etc.) cost less if I make less? No. I pay the same outrageously high overhead every month regardless of how much income I generate per month. (Physicians in private practice do not receive a salary; we are fee-for-service. If I see more patients, I make more money. If an unseasonably high number of patients “no show” on a particular month, or I go on a one-week vacation, or am out sick myself, my income is considerably less. If I make less, the owner of my building doesn’t charge me less that month. My malpractice insurance costs do not get lowered. So why should I charge less because someone is on the lower end of the pay scale?

"The option of rejecting care based on its price"
We cannot let patients pick and choose the parts of the medical care we provide. Your comment implies that everything we recommend/order is not necessary and that we just “throw in some extras” that are not necessary in order to make more money. For all honest physicians, that is simply not the case; we only order what we know is necessary and what the patient’s insurance will cover (because the majority of patients could not otherwise afford it). Based on the fact that what we order is a necessary part of treatment, if patients “pick and choose”, there will be bad outcomes. When these occur, medical boards and/or juries will not say “Oh, it’s OK, Dr. Smith, it’s not your fault because the patient didn’t follow your advice.” No, they sanction and sue the bejesus out of us. If this model of medical practice you propose were to come into play, in relatively short order there would be no physicians remaining that could afford to continue practicing medicine (if they still had their licenses after all those bad outcomes.)

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So, things may be different in a smaller city and I’m not sure if you’re
working with a big hospital system or are in private practice, which I
would imagine changes all these things. At this point i’ve mostly
interacted with large health care systems for years now; the only small,
office-based doctors we have are our kids’ pediatricians, who are fabulous,
but it seems much less common to be in private practice nowadays.

  1. Price transparency. Sure, for an office visit perhaps you bill insurance
    a specific amount based on how much you talk to the person, what you
    discuss, etc, now. But is this really the only, or even the best, way to
    work things out? Don’t we all agree that dealing with insurance companies
    basically sucks? Would you not be happier just, say, billing for an office
    visit by the hour and not having to dig up the CPT code?

If your’e ordering a test, you should have some set pricing schedule. If
you’re doing a procedure, you should, again, have a relatively simple
pricing schedule and get consent before you do it. I’m not saying how the
system is now, I’m saying how it should be. There is no other area of the
economy where you have *no idea *how much something is going to cost until
after you’ve gotten the bill. Also, just putting out there that fee for
service is one pricing model for care; salary is another, and there are
still others that use a subscription model. So there are ways to imagine
billing where price transparency is greater.

  1. Price negotiation. I’m not sure where you work (if you are in private
    practice, etc.), but what I’ve encountered using a big university-based
    healthcare system is that there are multiple prices already. My insurance
    company pays less than the “list price” and negotiates a different price
    for service than your insurance company and the person who pays most of all
    is the uninsured person. And, by the way, it actually already is possible
    to negotiate a totally different amount as a private payer. The point is, this
    is already being done, just under wraps    . I’m saying that instead of mutely
    accepting whatever bill is given, consumers be allowed to ask *in advance *how
    much things will cost and what they are willing to pay for them. In what
    other industry are you not given a quote for service?

That doesn’t necessarily mean you have to accept less payment for some
patients; it could be that the government’s role is to top up the cost for
low-income patients in some way (either through existing system like
Medicare or Medicaid, or some other system).

By the way, the person who makes less money *does often *pay less for the
same slice of bread, whether that be through Welfare payments, food stamps,
coupons, rebates, shopping around to different stores, etc… I’m not
saying that you, as a doctor, should get paid $5 for seeing a Medical
patient while Kim Kardashian pays $3000. Just that it’s not fair for a
person earning 20k a year to pay $300 for an office visit.

  1. I don’t believe doctors frivolously prescribe unnecessary drugs,
    procedures or tests on average. And I don’t anticipate that someone in the
    hospital in the middle of having a stroke will be rejecting a CT scan or
    rehabilitative therapy because it costs too much. This would mainly apply
    to what we consider elective surgeries or procedures, which maybe need to
    be done eventually, but are not super urgent. But someone should get to say
    "sorry, I don’t want to pay for an out-of-network anesthesiologist that
    you’ve decided to work with, even when you have multiple in-network
    colleagues who do similarly good work" Read some of the investigative
    pieces about Sutter Health in California. It’s kind of shocking how
    aggressive their billing practices are. I feel like there should be some
    way to say “no I don’t want to pay $50 for an aspirin that I could buy for
    10 cents down the street.”
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[quote=“Tia_G, post:9, topic:57362, full:true”]
I’m not
saying that you, as a doctor, should get paid $5 for seeing a Medical
patient while Kim Kardashian pays $3000. Just that it’s not fair for a
person earning 20k a year to pay $300 for an office visit.[/quote]I understand (and share) the sentiment here, but I think you confuse compassion with justice.

This is not a matter of fairness. If it was, then fairness would demand a variable pricing model for almost all goods and services. We could get sidetracked arguing over which goods and services should be included in the “fair” pricing model, but that concedes the point: Health Care is not unique in some way that makes this judgement of fairness exclusive to that industry.

Food, legal services, auto repair services, cars, clothing, plumbers, and on and on and on – poor people need these things. It’s a Pandora’s Box of countless content, based on a measure of “fair” that is ultimately subjective. As such, what is “fair” will then become political, and depend on who’s in power from time to time. Oh goody.

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Any out of pocket direct medical expenses should be treated as a tax credit. Similar to the child tax credit.

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