Design a better healthcare system

The Coffee Shop
1

This is somewhat related to Michael Moore’s “Sicko”, but I want this in a separate discussion because I don’t want to talk about the movie. It’s pretty clear to most people that this country is in need of health care reform with spiraling medical costs, plentiful malpractice suits, and more and more people living without medical insurance. Now, say the entire system is blown up and you get to decide how we start all over. How would you do it?

Typically, I see 3 general types of health care across the globe. The first kind is the private health insurance system (America) where whether you live or die is dependent upon how much profit the health insurance company wants to make that quarter. I’m being biased, but in general, it can be summed up in that statement. The other kind is what America Jr. (Canada) uses. It’s a socialized health care system where it costs little or nothing to receive care. However, care seems to be less than stellar and you have to wait a long time to receive some procedures because there is such a backlog of requests for medical care. The third option is the back alley doctors practicing medicine where you can get a kidney removed for $50 in Tijuana.

What would you like to see in your health care system? How would it work? Would it suit the needs of the poor and the affluent equally? Would it be left up to the government or private business to run it? Where would the costs come from?

Start at it and I’ll reply once this thread gets going for awhile.

2

I want #3, I could really use $50 bucks…

3

This is a subject very close to my heart.

All the evidence to date (see the OECD, Porter and Teisberg, WHO, Commonwealth fund for int health policty) suggests that the US healthcare system is killing 100k through medical errors and a further 100k through infections.

There are huge variances in the comparable data from the UK (socialised medicine) but the numbers that are available suggest comparable rates of infection and error.

However only ~12% and ~13% of UK and Canadians believe their health care systems need rebuilding versus 35% of the US (source commonwealth fund for int health policy) inspite of these long waits that the Americans are all led to believe that we have for both emergency and elective care. This I will come back to.

Per capita expenditure in the US in 2002 was approximately $5250 versus $2k in the UK and $2.75k in Canada (source WHO), it was growing at that time in the US and UK at 6% CAGR.

Basically from a quality and outcomes point of view both public and private health care suck but the socialised systems are less dissatisfied with theirs compared to the US.

Quality of care provided is simply an issue that is present irrespective of the health system in place and does not appear to be dependent on whether it is private or public. The issue in the US is that it costs a premium to receive mediocre healthcare.

There are hospitals in the US that are world class and kill people, learn about the case of Josie King who was admitted to Johns Hopkins with burns and died of dehydration because no member of staff listened to the family. (There were a whole host of reasons but it would never have happened if they had involved the family in the patients care)

I can provide an endless list of examples of comparable cases in the UK.

I think there are 2 issues that need to be debated. The first is the quality of healthcare provision. The second is access to health care.

The first is an issue that a number of organisations in the US are taking very seriously including Theda, Cleveland Clinic, Johns Hopkins, and Virgina Mason to name but 5.

The second issue is more a of a societal issue and basically boils down to the question “do we as a society have a responsibility to make healthcare available to all irrespective of ability to pay?”

Europe has broadly answered this question and said yes. There are a variety of models in place from insurance which I believe is mandatory in Holland to the socialised systems in France and the UK.

France and the UK have both determined that not only should health care be available to all but we should provide services within the community and have therefore both Acute and Primary care facilities throughout the countries.

I am completely partisan, I think the solution in the UK is a good one. I have private health insurance that kicks in if the wait for an elective procedure is more than 12 weeks. I should point out before everyone says that is outrageous that Thedacare in Wisconsin which is a Solucient Top 100 US hospitals wait for repairing a torn ACL 2 years ago was 18 weeks, so there was not a huge difference between their system and our own. There’s has improved immeasurably but more due to their CEO than anything else.

For emergency and urgent issues you would simply be seen immediately. Immediately could be up to 14 days but using Mamograms as an example, many organisations in the UK have been doing one stop clinics for women for years providing a physical exam, ultrasound, mamography and biopsy and results all on the same day. Clearly this is better for the patient alleviating anxeity but I am sure that there are people here that will go on to the Daily Mail and BBC web sites and find examples of where they system fails and hold that up as a reason to not do it.

Some organisations have been doing this for more than 10 years. Last year I was in Chicago at a teaching hospital that has just got to the point of providing mamography results on the same day.

If I were unfortunate to need an ambulance in an emergency in the UK I would dial 999.

Depending on the result of the call triage system I would be determined either a Cat A or a Cat B call. The response times for these in urban areas are 8 minutes and 14 minutes respectively and 19 minutes for B’s in rural areas.

I would then be taken depending on the problem to the local tertiary acute hospital.

Now the expertise in the care that you receive will depend on where you live. If you live in rural England you will probably go to a local hospital that is simply not equipped nor has the expertise to deal with everything.

I live in London so have access to some of the best teaching hospitals in the world. In London for a stroke I’d go to Kings, for neuro to Georges of Kings, cancer the Marsden.

I like our system because it provides access to basic care for all, irrespective of condition or ability to pay if you are diagnosed and admitted you will be treated.

I have chosen to “upgrade” my own coverage because I can and if I am unfortunately diagnosed with something that was elective in nature I can be seen when and where I want at my own convenience.

I think that there are issues with all the systems. The quality in all of them is pretty poor, being a top 100 hospital in the US does not mean you are receiving great care as the measure is relative to all the other hospitals.

The practice of evidence based medicine is sporadic, see Thedacare, and in spite of people preaching otherwise I could provide you with data on the different rates procedure carried out in various countries, or the amount of antibiotics administered per 100k of population and they demonstrate that the practice of medicine varies enormously.

I believe people should have access to healthcare and I also think we have a responsibility as a society to pay for it. I think that a private system generates perverse incentives, not least of which is you make money by not treating people so when confronted with the option of paying out or attempting not to you are certainly not going to be enthusiastic about the thought of losing money which is what a payout effectively is.

I think there are issues with the socialised systems. There are waits, there are issues with access, there are issues with quality but none of these are exclusive to the socialised systems.

The socialised systems have produced the first test tube babies, IVF and transplants off the top of my head and I think that whilst our system is far from perfect it serves the needs of our society well.

This is going to go down like a shit baloon with the righties…

4

No, you pay $50 to have a bad kidney removed.

5

Eric,

First, I have not seen, nor do I have any plans of seeing Moore’s new movie. So my comments are going to be from my thoughts based on what I have seen, experienced, and thought about. Basically, very little professional or expert opinions from this quarter.

Ideally, you would have a healthcare system where a doctor and his/her patient discuss intelligently matters of health with the goal of doing things to prevent the chronic diseases that can be prevented. So I think there would be an emphasis on wellness through diet, exercise, and overall healthy lifestyle.

Occasionally, acute problems occur. This is where the costs begin to mount. The hope is that by doing the aforementioned preventative stuff, much of this acute stuff doesn’t happen, or at least is reduced. Again, a Dr. and a reasonable patient should be able to figure out a treatment plan that does not include tests for overdiagnostics. I see this all of the time in the ER’s where doctors order a bunch of tests just because they want to rule out some obscure medical condition. I know that this savings alone won’t reduce a lot of costs in healthcare, but it will reduce some.

How to pay for it? Assuming we are not going to eliminate the 3rd party payer system, I’ll describe what I would like to see from an insurance. I like the idea of the patient paying out of pocket costs so that there is some consumer control over the costs. For insurance that is a benefit from a job, I would favor an 80/20 split with some kind of an HSA to cover out of pocket costs.

A lot of our problem though is the average consumer of health care. I really think that people don’t understand that stuff costs money and some stuff costs LOTS of money. I see this daily at my job. I can’t tell you how many people call 911 and expect us to take them to the hospital for literally no reason. Sometimes they want to get rid of their mother who has dementia for the night so that they can go to the bar (at least twice a month). Sometimes they want their kid taken to the hospital (5 blocks away) for a broken finger. Sometimes the police want us to take a drunk to the hospital because they don’t want to take him to jail. I shake my head in wonder, but there isn’t a blessed thing I can do about it. YET, all of these people get their ambulance rides ($550) and the insurance companies don’t bat an eye as they pay for it. In one moment of frustration a few years ago, I got into an argument with one of the patients because I knew that his complaints were BS. He knew the system though (as these kinds of folk do) and he looked at me and said, “Just take me to the hospital, kid. My insurance will pay for it.” I looked at him incredulously and said, “You’ve got insurance?” He replied, “Yep, I got that free insurance from the Government!” I nearly vommited all over that guy.

6

However only ~12% and ~13% of UK and Canadians believe their health care systems need rebuilding versus…

As a Canadian, I don’t believe that stat for a second.

7

Here is the bottom line, you can have any 2 of the following 3…

1 access to care

2 quality of care

3 affordable care

pick any combination you would like.

We do have a problem in the US in that the issurance companies have virtually no regulation, and now the middleclass is squeezed for every penny and in many instances refused insurance. Then the abusers who cry watching their big screen tv’s, talking on their cell phone, driving a bmw and yet cannot understand why they do not want to pay an insurance premium.

We have big problems that need some fixing!

8

I’d start by offering $10K tax free to any adult who would undergo a vasectomy or tubal ligation. Totally voluntary, you must be 18 years old. Fingerprinting/Drug screen to be done before the procedure (to be sure the patient was not under the influence and could not claim they did not know what they are doing). If you were a 20 y/o drug addict who wanted $10K to shoot up, fine, here you go. A 35 y/o male done having kids? Take your $10K and do as you please. 50 years old? No problem. Money to be direct deposited to avoid robberies when leaving the clinic.

I know there are holes in the plan, the bugs need to be worked out.

I’m betting the program would pay for itself immediately.

9

I cant validate whether the data is true or not, it was research conducted by the commonwealth international health fund, dont have it in front of me and was cited in Porters latest book.

Just because you dont believe it, does not mean it is not true. I’m not saying its right or wrong, just that you are not offering any evidence to contrary, just an opinion.

I believe that our system is different to the Canadian in that we have socialised medicine but also a private health and insurance system which run in parallel.

I do know that the data is true for the UK, the NHS is a national institution that the population feel strongly about, so much so that it is usually THE single most important political issue.

10

I just spent two years in England, and I heard more about the NHS than any other single topic. In addition, I had the opportunity to go with a friend to East Surrey Hospital. She has emphysema and was having an exacerbation. Although the staff was generally competent and polite, the level of care was modest at best. She was put into a ward with about 9 other people. (remember, for an emphysema patient the threat of pneumonia is a death threat) She was put on 5 liters of O2 by the charge nurse, but when the head nurse (I called her Ratchett) came on she asked who had ordered oxygen for my friend, because it’s addicting. LOL! Yes, as slowtwitchers everywhere will attest oxygen is addicting. But, the problem is that oxygen is a costly “medication”, or treatment, if you will. Many NHS trusts will not provide it to ambulatory emphysema patients. After 3 days in the hospital, she was kicked out because they needed the bed! Although she was still in pretty bad shape, her husband and I took her home and she survived your health care system. I would add that the physical plant at East Surrey is horrid. They are doing some new construction, so it may be up to snuff soon, but right now, the equipment and physical plant are WWII vintage.

The three major problems (passing the obvious bankruptcy of about 7 of the trusts) with your system from my perspective are:

  1. Funding for each NHS trust is done politically. They say not, but the reality is otherwise. Patricia Hewitt is a liar and a poor one. (NB: Oh, she’s now gone, with Brown in.)
  2. The quality of health care is very uneven.
  3. Too many people abuse the system. Well people clog the hospitals and surgeries.

There are many other problems, such as doctors and nurses who aren’t aware of current best practices. Which may explain why you would go to different hospitals in London for different conditions. Imagine being in Brighton or Kent?

-Robert

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**Per capita expenditure in the US in 2002 was approximately $5250 versus $2k in the UK and $2.75k in Canada (source WHO), it was growing at that time in the US and UK at 6% CAGR. **

I hear the cost argument thrown about as a justification for socialized medicine. While I agree that a socialized system should in theory be more efficient I do not believe that you can directly compare healthcase costs between countries. Americans on the whole are fat lazy bastards who have loads of problems with diabetes, high cholesterol, high blood pressure, heart attacks, and strokes. As a nation we are in worse health than most of the other developed nations. Also, we have a staggering illegal immigrant problem and there method of treatment is the ER. They can’t pay for these services and the hospitals must treat them. Therefore the ER must raise the rates on those who can pay. So, when looking at the total cost divided by the total number of US citizens (people who receive care) the denominator is off by at least a few million which would also make the per capita expenditures in the US higher than they truly are.

Personally, I think that a hybrid system would work the best in the US. A central gov’t authority would pay a set amount for routine visits and if patients wanted to visit a doctor who charges more then they are responsible for the extra cost.

12

as a former hospital employee I have my own view.

health care is not the problem. the way the system is set up. you have no way to negotiate prices. you get what they give you. cash gets you nowhere. the insurance companies dictate price. the free market is not present.

it bugs me when I hear that a % of the public has no health insurance. so what?? when I was in my 20’s I had no health insurance and didn’t want it. if I got injured I would self treat or seek free treatment from a community care agency. my tenant just had FREE hernia surgery. so to say someone has no insurance does not mean they do not have access to health care. I call it BS!!

13

I do not believe that you can directly compare healthcase costs between countries. Americans on the whole are fat lazy bastards who have loads of problems with diabetes, high cholesterol, high blood pressure, heart attacks, and strokes. As a nation we are in worse health than most of the other developed nations.

That’s along my line of thinking as well; the financial and practical costs of transitioning is incalculable in our current situation. In general, the focus needs to be in providing early and affordable preventative care access to affect change in future generations, much like the goal for equality in the workplace needs to be in improving early educational opportunities for the disadvantaged. The idea comports with the primary goal of health care in general, which is to keep people well, not finding ways to afford to cure the sick.

In my ideal scenario, universal health care would entail free and readily-available access with comprehensive coverage for the 0-18 age group, then pick up again upon entering the social security payout system. For the years in between, some sort of basic coverage with supplimental private insurance options seems reasonable.

14

so to say someone has no insurance does not mean they do not have access to health care.

  1. True. Without insurance, someone else STILL pays for their health care … not that they don’t receive health care. At this point we’re (society) just haggling how “formal” the process of those who can (or are willing) pay will actually pay for those that can’t/won’t pay. This is where I support a health care system if it’s going to provide affordable, accessible health care at a reasonable level of quality. I would like to see the national health care system tied to “wellness standards”, etc. Right now, we have Medi-caid, and any kid whose family receives free/reduced lunches for school is elgible for a health care card. In other words, the low income families are being taken care in the health care department.

  2. I admit, I’m tired of hearing about middle class folks that “can’t” afford health insurance. When I hear this I immediately want to know how much they spent on a house, what kind of car they drive, whether they spend $20 or $150 on extended-cable with high speed internet, how many vacations they take, etc. I say that with an understanding that, as Americans, we often live above our needs in the entertainment/toy department (and we seem to think we’re entitled to). In short, we spend our “hard earned” money on the fun-toy stuff because “we deserve it”, but we don’t spend our money on the stuff that we might actually need (preventative maintenance, healt insurance, etc).

15

On the other hand, I know of one case in college where a guy was mountain biking and took a fall. He banged his head pretty badly and totally destroyed his helmet. It wasn’t pretty and they had to call an ambulance and take him to the hospital. He had to have all kinds of neurological tests done to make sure he didn’t have major brain damage. He didn’t have any insurance at the time and his bill was outrageous. This is a catastrophic event and b/c he didn’t have any medical insurance, it cost him a lot of money. You said that you didn’t have any medical insurance in your 20’s. Well, how can you prevent something like a major car crash? What would you have done if that happened to you when you had no medical insurance and you were left with a hospital bill of $50k?

Also, I disagree that the free market is not present in the current health care system. It is present and because of the free market and the power of cash used not in the interest of the consumer, it has become the cluster fuck that it has become. Now, let’s say that John Q. Public is a member of Acme Health Care (ACM) which is the nation’s largest medical insurance company. He has an accident and has to go to the hospital. ACM has an agreement with the hospital that they’ll have to perform around 50 instances of Procedure X. So, ACM has negotiated with the hospital a cost for 50 instances of Procedure X and since they are buying this in bulk, they get a price of $200 per instance. Now, Joe Q. Public does not have insurance and has the same accident as John and has to have the same Procedure X done. Since he is only buying one instance of Procedure X, he doesn’t get any bulk discount and he has to pay $2,000 for it. I understand that this is business and it’s completely legitimate for ACM to negotiate the lower rate, but this is also life and death and which is more important: someone living or someone else making money?

16

I’ll take our Canadian system over the USA any day.

It has some problems that need addressing for sure, but at least every single Canadian citizen has health care. We’re different fom the US as we regard universal health care as a right. It’s our most apple pie issue.

17

**True. Without insurance, someone else STILL pays for their health care **

if that is the question, I would much perfer that society help out than government. in my little city of 100k there is a free community clinics for the poor to seek care. there are several private agencies that provide free or cheap care. I do not want to see the gov open another entitlement program. IMHO the government is incompetant.

2. I admit, I’m tired of hearing about middle class folks that “can’t” afford health insurance.

that could be expanded to include personal debt, diet, lack of exercise, lack of savings, lack of investment for retirement, and a general lack of personal responsibility.

18

I do not want to see the gov open another entitlement program.

This is my big complaint/concern. Obviusly, as a principal at a high low-come school (like ~75%) I am biased, and I don’t pretend I’m not … but I would rather see more of that money go back into education and equalization regarding access to resources and support of the student (i.e., social workers, counselers, etc) versus more “stay on the teet” programs, where the government is the parent and the adults are the childer always looking for their allowance. Provide people with a means of self-sufficiency and upward mobilty (whether they want it or not).

Alas, in our current democracy, we have reached the point that the people have figured out that they can vote in whoever gives them the most stuff. So, not many realistic candidates are going to run on a platform of education, hard work, self-improvement, and individual responsibility.

19

OK, it’s time for me to input what I think the best system is. I know that it is very idealistic, but I’m trying to balance the needs of the consumer to receive quality medical care for relatively inexpensive, the opportunity for doctors and other medical professionals to receive a appropriate income, and the opportunity for private medical insurance companies to make money as well. Yeah, I know I can’t balance all of those, but I’ll try.

Option 1:
In this option, I believe that it is very important for everyone to receive basic medical care. This is probably more of a socialistic health care system, but let me explain how I think it should work. Everyone has access to medical care through public, government hospitals. Most visits would have a copay, something like $10 or $20 per visit, and this is designed to do two things: 1) have some sort of income from patients using the facilities and 2) to put some kind of preventative measure in there so that it isn’t free and the system gets bogged down with someone coming in one week for a paper cut, the next week with the sniffles, and the third week. I’ve heard stories in Canada that this happens a lot with their free from direct payment, socialistic health care system. Preventative procedures such as an annual checkup, mammograms, prostate exams, and a few other procedures would be free. The idea is to get the less than health conscious people to come in and get preventative procedures which will hopefully reduce the overall costs of health care by catching things early.

If you don’t want to receive just the basic medical care, you can opt out of the government system and get a credit towards a private insurance plan very similar to the more common plans today, but the consumer would also pay a premium. However, I feel like government should have a much larger role in regulating the industry. In the basic medical care above, the government does the regulation and provides most of the money for the payment of the procedures, and basically provides the care through state run hospitals, clinics, etc. In this plan, the government does the regulation, the consumer will provide a larger portion of the payment with a portion of it coming from private health insurance companies, and the care is provided through private practitioners, hospitals, and clinics. Like I said, the biggest thing is more government regulation to prevent the great discrepancy between the battle of the life of the patient versus the profits of the company. Also, I think there should be higher premiums for certain lifestyle choices. For example, if you smoke, that’s a 50% premium. If you are obese according to the BMI scale, (note that I did not say overweight since according to the BMI scale, I’m overweight which is not the case), then you pay a 25% premium. If you live an active, healthy lifestyle, you should get a discount on the health insurance premiums. This provides financial incentive for people to live healthier lifestyles and everyone knows that the best way to affect the general public’s behavior is to affect their pocketbooks.

Now, you have a system where you have state run hospitals and private hospitals. There would essentially be 2 systems to treat 2 different kinds of patients. However, the only way that a state hospital would treat a private insurance person would be in a life threatening emergency and vice versa for the public patient and private hospital. I know that this is very idealistic, but it’s an idea. Hopefully, having two systems like this would allow consumers to choose how much care they would want. The basic care is relatively very inexpensive and it allows people to have the comfort that if something happens, they can get treated. They may not have access to the best medical care in the industry such as that from John Hopkins nor will they be able to have access to get procedures done quickly, but they will have care. If someone wants to pay to have potentially better care and quicker access to procedures, they can get that through the private insurance method. Also, this would hopefully create a system where taxes would not need to be increased or increased much to pay for the state run system since most people will opt to take the private insurance system and the government doesn’t have to pay as much for their care since all they have to do is pay a certain credit to the private insurance companies.

Option 2:
Have a socialistic health care system similar to Canada. However, institute a copay system where every visit. The copay would be based upon your income tax bracket. You make less money, you pay less. You make more money, you pay more because you are able to afford it. Also, this prevents people from trying to see a doctor whenever any minor thing comes up since seeing a doctor is “free”. I’m not going to explain this as much because I have to get some work done today.

20

2. I admit, I’m tired of hearing about middle class folks that “can’t” afford health insurance.

that could be expanded to include personal debt, diet, lack of exercise, lack of savings, lack of investment for retirement, and a general lack of personal responsibility.

That’s one of the problems with the current system. Since I’m in a big company with 7000 employees, and I live an active, healthy lifestyle where I eat clean foods, I exercise, and my risk of heard disease, diabetes, cancer, and other debilitating and expensive ailments, I actually have no incentive to live this lifestyle since the person in the cube next to me pays the same amount a month for health insurance even though they eat fast food 5 days a week, is 75 pounds overweight, never exercises, smokes 2 packs per day, etc. We need to have some kind of financial incentive through cost of health insurance for people to live a healthy lifestyle besides the feeling of being healthy. Unfortunately, pleasure in America revolves around money and you must make people feel tightness not in their waistlines, but in their pocketbooks, because they are living an unhealthy lifestyle.