RIP off in healthcare

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dshibb said:   Look glxpass, I believe you have the capacity to really think of various solutions and ideas to address this that fit within your own moral scope of the issue. I mean seriously putting aside whatever political bull$hit that everybody else wants to go back and forth over, I actually think you and many other people on here are smart enough to come up with original ideas that better address this problem than what we currently have.

And that problem is how to reconcile these 2 things the best way we can:
1) To make sure that we have a healthcare system where we feel comfortable with moral question of people being able to get treatment
and
2) For people to act like the money that is being spent to better their health is their own

Because honestly if tomorrow people acted like $300k to extend their life by a couple of months or $10k to see a specialist for a small issue was their money most of the time they would choose something different(and the systemic cost problem would subside), but at the same if it was really important to them they could have the financial capacity to do it if they really wanted it. That is the question right there. And I think your better than most people who would prefer to keep this topic within their own 'political comfort zone' because if I can put aside any sense of my political comfort zone so can you. My side of aisle has a political comfort zone about life not being fair and I tend to agree with that, but I'm willing to set that aside to acknowledge that there is something right about trying to make sure anybody can get care regardless of their means. But you should also rise to the challenge and agree that there is something important about people taking responsibility for finding relative value in the large sums of money that are spent on their behalf. Being sick should not be an excuse to spend other people's money irresponsibly while seeking care.

Now I've engaged in the type of conversation with numerous people and most refuse to rise to the challenge and that has generally speaking left me a little jaded about people's desire to put the bull$hit aside and rise to the challenge. I guess, surprise me!

I appreciate your willingness to step outside of your political comfort zone, and I agree that while we need a healthcare system that provides adequate services to all, unless we can find a way to contain and reduce healthcare costs, we will eventually go bankrupt. One significant component of healthcare cost is unhealthy lifestyle choices. Note that I consider addressing this component as necessary but not sufficient to "get a handle" on healthcare costs. See this white paper fhat discusses reducing annual healthcare costs by $700: http://www.factsforhealthcare.com/whitepaper/HealthcareWaste.pdf

Nevertheless, let's return to the topic of incentivizing healthy lifestyle choices. I agree that everyone must take ownership of their personal health. You and Brody seem to think that said ownership requires at the very least an increase in deductibles, perhaps directly proportional to the cost of whatever medical service us provided. I see flaws in this approach:

1. You are focusing on cost, not value of a healthcare service. Areas of concern are high cost, low value services. High cost, high value services are another matter. Low cost, high value services are ideal, but obviously not always achievable.

2. Increasing the deductible will discourage people from getting health care even when they should. An example (numbers are guesstimates, but probably on the low side): Person X has had two DVTs (one in each calf) over the last 18 months and is now on constant Coumadin therapy. Diagnosis was by ultrasound. The total cost of the ultrasound, including labor, is $1000. One evening, person X notes a pain in the right groin area. it could simply be a pulled muscle, although person X had no recollection of any trauma that might account for this. Could it be another DVT? An ER visit might cost $3000. Should person X's decision about seeking treatment be driven by treatment cost and/or financial situation? No, it shouldn't.

BTW, you'll be happy to learn that person X went to the ER, and despite having taken Coumadin as directed, person X in fact had a DVT, which required hospitalization in the ICU and additional treatment. Total cost: $40,000. it was a good thing that person X didn't have a high-deductible insurance plan whose cost might have made him defer treatment, possibly resulting in a worse outcome, to put it mildly.

3. IMO, although promoting healthy lifestyles should reduce healthcare costs, that's a byproduct, not a rationale.

I would have preferred policies with a very high deductible ("VHDHP") and some cost sharing above the deductible to most other options. For example, an individual policy with a $10K deductible, 10% cost sharing and a maximum out of pocket of $20K. The cost of this policy could be offset by a refundable tax credit.

This approach gives everyone "free" health insurance, increases the incentive to conserve costs and offers insurer negotiated prices for health care. If someone shows up at the ER, they would be automatically enrolled in a VHDHP.

Below the deductible, people could purchase "gap" coverage according to their individual needs at a cost based on their risk profile. These policies could be offer preventive care and a limited number of discounted primary care and specialist visits per year. Subsidies to purchase this "gap" coverage would be income-based.

Warren Buffet would pay a maximum of $20K per year for health care. In contrast, Warren, who refills the dishes at a buffet, might pay only a small portion of the actual cost of an expensive hospital stay.

BrodyInsurance said:   glxpass said: Please say why you like that "this [raising deductibles] would cost unhealthy people more". There are plenty of "unhealthy people" whose health issues are no fault of their own, both children and adults.

First of all, just because something isn't one's fault, doesn't mean that the burden shouldn't fall on their shoulders. The choice, regardless of the subject at hand, is to either pay for the things that we use or have others pay for the things that we use.

The first sentence I disagree with; The second presents a false dichotomy. Like many other public services, essential healthcare costs are (or should be) borne by society as a whole, not portioned out by individual need. The challenge is to differentiate between essential costs and non-essential ones. Naturally, we should encourage healthy lifestyles and work on eliminating the huge amount of waste in our current healthcare system. That will benefit all of us.

It isn't my fault if my child has expensive medical issues. It isn't his fault either. However, if I choose to bring children into this world isn't it my responsibility to take care of them? It shouldn't be your responsibility to take care of my child.

That being said, I understand that medical issues aren't the same as many other things and we don't want someone being bankrupt because of medical conditions. High deductibles very much work out as a compromise.

I very much agree about medical issues being different than many other things and wanting to prevent bankruptcy.

It makes sense to me that those who use more medical services should pay more money than those who use less services. Doesn't that make sense to you? Imagine that all health insurance had a $10,000 deductible. If someone needed hundreds of thousands of medical care, health insurance would still be paying most of their cost. However, if you routinely have $5,000 in medical expenses a year and I have $2,000, should I be splitting this cost with you? I don't think so.

If you choose to have 12 kids and I have 2 kids, should we each be paying for 7 kids for insurance?

If I am the person who is routinely having $5,000 in medical expenses instead of $2,000, there is incentive for me to try to do things to try to become healthier. We don't need the government pushing us to do what they think is healthier.

Again, my answer is that healthcare costs are a societal expense. As I said in another post, becoming healthier is an end itself. I believe with proper education, most people will understand that. Healthcare costs will (I hope) decrease as a result.

What if someone can't afford a high deductible? Well if they can't afford the deductible, they also couldn't afford the insurance if the plan wasn't high deductible. High deductible plans come with a much lower premium.
I'm curious: How would you handle the situation where someone can't afford to pay?

High deductibles, in my opinion, have a few major advantages.

1)It makes health insurance "health insurance" instead of "pre-paid medical care".
2) It puts people and their doctors more in charge of their medical care than the insurance company.
3)It gets rid of most of the B.S. about what has to be covered.
4)It makes people care about costs.
5)There is a financial incentive to take care of one's health.
6)The amount of money that one pays in medical expenses is more in line with the amount of actual medical care received.
7)It makes people more personally responsible for their medical care.

I believe you've already brought up a number of these points, but it's useful to see your summary.

Here's something to consider: Perhaps heathcare shouldn't follow a fee-for-service model. See this Wikipedia entry:

http://en.wikipedia.org/wiki/Overutilization

glxpass said:   dshibb said:   Look glxpass, I believe you have the capacity to really think of various solutions and ideas to address this that fit within your own moral scope of the issue. I mean seriously putting aside whatever political bull$hit that everybody else wants to go back and forth over, I actually think you and many other people on here are smart enough to come up with original ideas that better address this problem than what we currently have.

And that problem is how to reconcile these 2 things the best way we can:
1) To make sure that we have a healthcare system where we feel comfortable with moral question of people being able to get treatment
and
2) For people to act like the money that is being spent to better their health is their own

Because honestly if tomorrow people acted like $300k to extend their life by a couple of months or $10k to see a specialist for a small issue was their money most of the time they would choose something different(and the systemic cost problem would subside), but at the same if it was really important to them they could have the financial capacity to do it if they really wanted it. That is the question right there. And I think your better than most people who would prefer to keep this topic within their own 'political comfort zone' because if I can put aside any sense of my political comfort zone so can you. My side of aisle has a political comfort zone about life not being fair and I tend to agree with that, but I'm willing to set that aside to acknowledge that there is something right about trying to make sure anybody can get care regardless of their means. But you should also rise to the challenge and agree that there is something important about people taking responsibility for finding relative value in the large sums of money that are spent on their behalf. Being sick should not be an excuse to spend other people's money irresponsibly while seeking care.

Now I've engaged in the type of conversation with numerous people and most refuse to rise to the challenge and that has generally speaking left me a little jaded about people's desire to put the bull$hit aside and rise to the challenge. I guess, surprise me!

I appreciate your willingness to step outside of your political comfort zone, and I agree that while we need a healthcare system that provides adequate services to all, unless we can find a way to contain and reduce healthcare costs, we will eventually go bankrupt. One significant component of healthcare cost is unhealthy lifestyle choices. Note that I consider addressing this component as necessary but not sufficient to "get a handle" on healthcare costs. See this white paper fhat discusses reducing annual healthcare costs by $700: http://www.factsforhealthcare.com/whitepaper/HealthcareWaste.pdf

Nevertheless, let's return to the topic of incentivizing healthy lifestyle choices. I agree that everyone must take ownership of their personal health. You and Brody seem to think that said ownership requires at the very least an increase in deductibles, perhaps directly proportional to the cost of whatever medical service us provided. I see flaws in this approach:

1. You are focusing on cost, not value of a healthcare service. Areas of concern are high cost, low value services. High cost, high value services are another matter. Low cost, high value services are ideal, but obviously not always achievable.

2. Increasing the deductible will discourage people from getting health care even when they should. An example (numbers are guesstimates, but probably on the low side): Person X has had two DVTs (one in each calf) over the last 18 months and is now on constant Coumadin therapy. Diagnosis was by ultrasound. The total cost of the ultrasound, including labor, is $1000. One evening, person X notes a pain in the right groin area. it could simply be a pulled muscle, although person X had no recollection of any trauma that might account for this. Could it be another DVT? An ER visit might cost $3000. Should person X's decision about seeking treatment be driven by treatment cost and/or financial situation? No, it shouldn't.

BTW, you'll be happy to learn that person X went to the ER, and despite having taken Coumadin as directed, person X in fact had a DVT, which required hospitalization in the ICU and additional treatment. Total cost: $40,000. it was a good thing that person X didn't have a high-deductible insurance plan whose cost might have made him defer treatment, possibly resulting in a worse outcome, to put it mildly.

3. IMO, although promoting healthy lifestyles should reduce healthcare costs, that's a byproduct, not a rationale.


You disappoint me! You're either can't follow what we're saying(doubtful) or trying not to follow what we're saying.

You had someone put aside the bull$hit in a post and then instead of doing the same you changed the subject.

Sad!

For other people that are capable of staying with what I said above, I'll throw out another interesting idea that I'm aware of.

You can also look at above the mark cost sharing. I.e. today once you hit your deductible you always incentivized to get the best the available because someone else is paying for the bill. An interesting solution is for the 3rd party payer(likely an insurance company) agrees to pay the full amount for the cheaper option. If you want the more expensive option you can pay for all or a larger portion of the difference between the cheaper option and the more expensive option. All of a sudden people will really think about whether that higher quality option is actually worth the extra expense.

Of course the key issue for such a solution is it's a boondoggle to try to implement, but pilot programs have been thought about for potentially used in managed care type plans.


Also, you can manipulate this a bit. Let's say instead of insurers setting the cheaper option as the benchmark they set the average as a benchmark and then if a cheaper option was chosen the insurer writes out a check to the insured for the difference or part of the difference and if a more expensive option than the average is chosen than the individual pays out all or a larger part of the difference between the average and the higher cost option they decide on. Again implementation is where something like this gets tricky, but if you could pull it off a solution like this could cause people to be a lot more discerning about what kinds of treatments they choose to receive and start to pick the cheaper options.

Just some food for thought.

dshibb said:   glxpass said:   dshibb said:   Look glxpass, I believe you have the capacity to really think of various solutions and ideas to address this that fit within your own moral scope of the issue. I mean seriously putting aside whatever political bull$hit that everybody else wants to go back and forth over, I actually think you and many other people on here are smart enough to come up with original ideas that better address this problem than what we currently have.

And that problem is how to reconcile these 2 things the best way we can:
1) To make sure that we have a healthcare system where we feel comfortable with moral question of people being able to get treatment
and
2) For people to act like the money that is being spent to better their health is their own

Because honestly if tomorrow people acted like $300k to extend their life by a couple of months or $10k to see a specialist for a small issue was their money most of the time they would choose something different(and the systemic cost problem would subside), but at the same if it was really important to them they could have the financial capacity to do it if they really wanted it. That is the question right there. And I think your better than most people who would prefer to keep this topic within their own 'political comfort zone' because if I can put aside any sense of my political comfort zone so can you. My side of aisle has a political comfort zone about life not being fair and I tend to agree with that, but I'm willing to set that aside to acknowledge that there is something right about trying to make sure anybody can get care regardless of their means. But you should also rise to the challenge and agree that there is something important about people taking responsibility for finding relative value in the large sums of money that are spent on their behalf. Being sick should not be an excuse to spend other people's money irresponsibly while seeking care.

Now I've engaged in the type of conversation with numerous people and most refuse to rise to the challenge and that has generally speaking left me a little jaded about people's desire to put the bull$hit aside and rise to the challenge. I guess, surprise me!

I appreciate your willingness to step outside of your political comfort zone, and I agree that while we need a healthcare system that provides adequate services to all, unless we can find a way to contain and reduce healthcare costs, we will eventually go bankrupt. One significant component of healthcare cost is unhealthy lifestyle choices. Note that I consider addressing this component as necessary but not sufficient to "get a handle" on healthcare costs. See this white paper fhat discusses reducing annual healthcare costs by $700: http://www.factsforhealthcare.com/whitepaper/HealthcareWaste.pdf

Nevertheless, let's return to the topic of incentivizing healthy lifestyle choices. I agree that everyone must take ownership of their personal health. You and Brody seem to think that said ownership requires at the very least an increase in deductibles, perhaps directly proportional to the cost of whatever medical service us provided. I see flaws in this approach:

1. You are focusing on cost, not value of a healthcare service. Areas of concern are high cost, low value services. High cost, high value services are another matter. Low cost, high value services are ideal, but obviously not always achievable.

2. Increasing the deductible will discourage people from getting health care even when they should. An example (numbers are guesstimates, but probably on the low side): Person X has had two DVTs (one in each calf) over the last 18 months and is now on constant Coumadin therapy. Diagnosis was by ultrasound. The total cost of the ultrasound, including labor, is $1000. One evening, person X notes a pain in the right groin area. it could simply be a pulled muscle, although person X had no recollection of any trauma that might account for this. Could it be another DVT? An ER visit might cost $3000. Should person X's decision about seeking treatment be driven by treatment cost and/or financial situation? No, it shouldn't.

BTW, you'll be happy to learn that person X went to the ER, and despite having taken Coumadin as directed, person X in fact had a DVT, which required hospitalization in the ICU and additional treatment. Total cost: $40,000. it was a good thing that person X didn't have a high-deductible insurance plan whose cost might have made him defer treatment, possibly resulting in a worse outcome, to put it mildly.

3. IMO, although promoting healthy lifestyles should reduce healthcare costs, that's a byproduct, not a rationale.


You disappoint me! You're either can't follow what we're saying(doubtful) or trying not to follow what we're saying.

You had someone put aside the bull$hit in a post and then instead of doing the same you changed the subject.

Sad!

You don't always get to dictate the terms of discussion. I explained rather clearly (or so I thought) where and why I disagreed with your POV. Your and BrodyInsurances's posts inspired me to look further into the issue, and for that I'm grateful. We are probably at an impasse, but if you insist on personalizing things, so be it. It's good to be passionate about an issue, but please don't take out your frustrations on others.

glxpass said:   dshibb said:   glxpass said:   dshibb said:   Look glxpass, I believe you have the capacity to really think of various solutions and ideas to address this that fit within your own moral scope of the issue. I mean seriously putting aside whatever political bull$hit that everybody else wants to go back and forth over, I actually think you and many other people on here are smart enough to come up with original ideas that better address this problem than what we currently have.

And that problem is how to reconcile these 2 things the best way we can:
1) To make sure that we have a healthcare system where we feel comfortable with moral question of people being able to get treatment
and
2) For people to act like the money that is being spent to better their health is their own

Because honestly if tomorrow people acted like $300k to extend their life by a couple of months or $10k to see a specialist for a small issue was their money most of the time they would choose something different(and the systemic cost problem would subside), but at the same if it was really important to them they could have the financial capacity to do it if they really wanted it. That is the question right there. And I think your better than most people who would prefer to keep this topic within their own 'political comfort zone' because if I can put aside any sense of my political comfort zone so can you. My side of aisle has a political comfort zone about life not being fair and I tend to agree with that, but I'm willing to set that aside to acknowledge that there is something right about trying to make sure anybody can get care regardless of their means. But you should also rise to the challenge and agree that there is something important about people taking responsibility for finding relative value in the large sums of money that are spent on their behalf. Being sick should not be an excuse to spend other people's money irresponsibly while seeking care.

Now I've engaged in the type of conversation with numerous people and most refuse to rise to the challenge and that has generally speaking left me a little jaded about people's desire to put the bull$hit aside and rise to the challenge. I guess, surprise me!

I appreciate your willingness to step outside of your political comfort zone, and I agree that while we need a healthcare system that provides adequate services to all, unless we can find a way to contain and reduce healthcare costs, we will eventually go bankrupt. One significant component of healthcare cost is unhealthy lifestyle choices. Note that I consider addressing this component as necessary but not sufficient to "get a handle" on healthcare costs. See this white paper fhat discusses reducing annual healthcare costs by $700: http://www.factsforhealthcare.com/whitepaper/HealthcareWaste.pdf

Nevertheless, let's return to the topic of incentivizing healthy lifestyle choices. I agree that everyone must take ownership of their personal health. You and Brody seem to think that said ownership requires at the very least an increase in deductibles, perhaps directly proportional to the cost of whatever medical service us provided. I see flaws in this approach:

1. You are focusing on cost, not value of a healthcare service. Areas of concern are high cost, low value services. High cost, high value services are another matter. Low cost, high value services are ideal, but obviously not always achievable.

2. Increasing the deductible will discourage people from getting health care even when they should. An example (numbers are guesstimates, but probably on the low side): Person X has had two DVTs (one in each calf) over the last 18 months and is now on constant Coumadin therapy. Diagnosis was by ultrasound. The total cost of the ultrasound, including labor, is $1000. One evening, person X notes a pain in the right groin area. it could simply be a pulled muscle, although person X had no recollection of any trauma that might account for this. Could it be another DVT? An ER visit might cost $3000. Should person X's decision about seeking treatment be driven by treatment cost and/or financial situation? No, it shouldn't.

BTW, you'll be happy to learn that person X went to the ER, and despite having taken Coumadin as directed, person X in fact had a DVT, which required hospitalization in the ICU and additional treatment. Total cost: $40,000. it was a good thing that person X didn't have a high-deductible insurance plan whose cost might have made him defer treatment, possibly resulting in a worse outcome, to put it mildly.

3. IMO, although promoting healthy lifestyles should reduce healthcare costs, that's a byproduct, not a rationale.


You disappoint me! You're either can't follow what we're saying(doubtful) or trying not to follow what we're saying.

You had someone put aside the bull$hit in a post and then instead of doing the same you changed the subject.

Sad!

You don't always get to dictate the terms of discussion. I explained rather clearly (or so I thought) where and why I disagreed with your POV. Your and BrodyInsurances's posts inspired me to look further into the issue, and for that I'm grateful. We are probably at an impasse, but if you insist on personalizing things, so be it. It's good to be passionate about an issue, but please don't take out your frustrations on others.


Actually no you didn't. You basically said thanks for sharing something that I agree with now allow me to change the subject to this other factor I think is affecting cost and completely ignore everything else you said.

And if to you that looked like I was trying to dictate the terms of discussion than I feel sorry for you. I was going out on a limb and you didn't even have a level of respect to even address me and instead just changed the subject.

So I'll repeat *sad*.

BrodyInsurance said:   High deductibles, in my opinion, have a few major advantages.

1)It makes health insurance "health insurance" instead of "pre-paid medical care".
2) It puts people and their doctors more in charge of their medical care than the insurance company.
3)It gets rid of most of the B.S. about what has to be covered.
4)It makes people care about costs.
5)There is a financial incentive to take care of one's health.
6)The amount of money that one pays in medical expenses is more in line with the amount of actual medical care received.
7)It makes people more personally responsible for their medical care.

Mostly agreed, except that most health issues are the type which cost a little if caught early, cost a lot if treated later. If you've got a cough and the doctor figures out it's pneumonia, a few weeks of antibiotics takes care of it. But if you don't visit the doctor because you don't want to pay the deductible and it turns into full-blown pneumonia, now you're looking at a hospital stay and maybe some time in intensive care.

So I'd amend your suggestion to exclude annual checkups and n doctor's office visits each year from the deductible (where n = 3-6). Maybe even lower the deductible if you went to see a doctor when you first began experiencing symptoms, rather than waited until you felt like you were at death's door. Encourage people to go see the doctor early if they're injured or sick. Not avoid the doctor just because you don't want to pay the deductible.

Solandri said:   BrodyInsurance said:   High deductibles, in my opinion, have a few major advantages.

1)It makes health insurance "health insurance" instead of "pre-paid medical care".
2) It puts people and their doctors more in charge of their medical care than the insurance company.
3)It gets rid of most of the B.S. about what has to be covered.
4)It makes people care about costs.
5)There is a financial incentive to take care of one's health.
6)The amount of money that one pays in medical expenses is more in line with the amount of actual medical care received.
7)It makes people more personally responsible for their medical care.

Mostly agreed, except that most health issues are the type which cost a little if caught early, cost a lot if treated later. If you've got a cough and the doctor figures out it's pneumonia, a few weeks of antibiotics takes care of it. But if you don't visit the doctor because you don't want to pay the deductible and it turns into full-blown pneumonia, now you're looking at a hospital stay and maybe some time in intensive care.

So I'd amend your suggestion to exclude annual checkups and n doctor's office visits each year from the deductible (where n = 3-6). Maybe even lower the deductible if you went to see a doctor when you first began experiencing symptoms, rather than waited until you felt like you were at death's door. Encourage people to go see the doctor early if they're injured or sick. Not avoid the doctor just because you don't want to pay the deductible.


This is a valid point, but insurance companies were already taken steps to address this because as you pointed out if failing to discover something ends up in higher costs they're the ones that will be forced to pick up the tab so it's in their financial interest to provide *certain* services free or at a reduced cost which is what they were trying to do.

Many insurance carriers/private companies were starting addressing this in one of 2 ways. Either start handing out free or reduced price physicals, free or reduced price gym memberships, various forms of free or reduced price tests, various forms of free or reduced price vaccinations, etc. or often times providing rewards at the end of the year for doing these things after the fact.

There is actually a ton of pilot projects and research that has exploded in this area and insurers have proactively tried to discern the difference between cost effective preventative medicine that will lower costs over the long term and unnecessary preventative costs that will only result in higher costs today without cost benefits in the future. They still have a long way to go in that area, but if there is true preventive medicine that will reduce future costs it's actually in their interests to find that and make it easier for people to obtain. Regardless of where it stands today eventually they'll have identified all of the cost effective preventative measures because over time entities always move towards what it is in there financial interests to do.


Another solution that may be worth looking at is offering to reimburse more than the cost of successful preventative measures if they are discovered. What I mean by that is if I go to the hospital for a test because I think I might have x and they come up negative I'm subject to pay for said test and that counts towards my deductible. Now on the flip side if I turn up positive than not only does my costs for going to the hospital to get that test covered, but the insurance carrier sends me a check for an even larger amount.

What situation does this create? Well now all of a sudden if I actually think I might have something I may not just look at the cost of going to have it checked out, I might also realize that if I do come up positive that I may actually receive money so from a financial standpoint I'm less inclined to avoid the cost of the test if it's something I think I should actually be worried about.

BrodyInsurance said:   I suspect our basic assumptions differ. I think the key to lowering healthcare costs lies in education rather than financial incentives. Financial incentives such as reduction of premiums, can however motivate employers to promote healthy lifestyles among their employees.

I admit this becomes much harder when dealing with the unemployed or retired, but the object is the same: to put a value on good health for its own sake.

I'd welcome thoughts on how to accomplish this. I think that's the direction we need to take.


I think that you are asking the impossible. What you are proposing is your results will be based upon the actions of a group. Let's try a couple of analogies.

100 people are going out to dinner at Applebee's. They are allowed to order whatever they like. The bill will be shared equally. What would you recommend to make the total bill the lowest?

100 students are in a class. The teacher tells them that they will all receive the same grade. What would you do to make this grade the highest?

100 people are sharing medical expenses. Each person is going to pay 1% of the total medical expenses. What would you do to lower this cost?

If I wanted dinner to be at the lowest possible charge, the grades to be the highest average, or the medical costs to be the lowest, I would change it from a group sharing approach and make everyone responsible for their own costs/grades.

I am relatively certain that this will do much more than any possible suggestion that you might have. Additionally, any suggestion that you might have can probably be combined with people being responsible for their own costs/grades.

I understand that a complete individual cost responsibility doesn't work for health care because we do want people who need care, but can't afford that care, to be able to get it. I am just suggesting that we make people responsible for themselves as much as possible. A high deductible plan does this. Everyone is responsible for themselves, but only up to a certain point. We recognize the necessity of some cost sharing.

This is how that would work with those other analogies.
Applebees: The price of everyone's entree's would be shared, but if someone chooses to buy drinks, appetizers, or desserts, the individual would pay themselves.
Grades: 50% of the cost will be based upon individual effort and 50% of the grade is based upon the class project.
Health Care: Everyone is responsible for their own costs. All costs above $X are shared.

but the object is the same: to put a value on good health for its own sake.
Why should we be putting a value on that? I mean that it is certainly something that I value. It doesn't have to be a value that you have. If you care more about sitting around eating bonbons and watching tv, why does that need to be an issue for everybody else? The object is to lower medical expenses. If the bill is being shared equally, valuing good health can very easily mean a huge increase in medical expenses. If someone else is footing the bill, why would you not get every single preventive medical measure done? You certainly would have zero incentive to do any cost/benefit analysis.

Your analogies would be appropriate if our actions only affected ourselves and not others. That isn't true for healthcare. Take employer health coverage. The plans I've participated in have had the same premiums regardless of age or health condition. Premiums might or might not vary based on member, member + spouse, and family coverage. How do employers attempt to control costs without loss of benefits? One method is to develop employee wellness programs and encourage participation in those programs. Although incentives, financial and otherwise, can be offered for employee participation, i contend that most people would rather be in good health than in poor health and are thus receptive to education.

Health education isn't just the province of employers. I've seen clinics offer classes and seminars that focus on preventive care, as well as palliative care.

glxpass said:   BrodyInsurance said:   I suspect our basic assumptions differ. I think the key to lowering healthcare costs lies in education rather than financial incentives. Financial incentives such as reduction of premiums, can however motivate employers to promote healthy lifestyles among their employees.

I admit this becomes much harder when dealing with the unemployed or retired, but the object is the same: to put a value on good health for its own sake.

I'd welcome thoughts on how to accomplish this. I think that's the direction we need to take.


I think that you are asking the impossible. What you are proposing is your results will be based upon the actions of a group. Let's try a couple of analogies.

100 people are going out to dinner at Applebee's. They are allowed to order whatever they like. The bill will be shared equally. What would you recommend to make the total bill the lowest?

100 students are in a class. The teacher tells them that they will all receive the same grade. What would you do to make this grade the highest?

100 people are sharing medical expenses. Each person is going to pay 1% of the total medical expenses. What would you do to lower this cost?

If I wanted dinner to be at the lowest possible charge, the grades to be the highest average, or the medical costs to be the lowest, I would change it from a group sharing approach and make everyone responsible for their own costs/grades.

I am relatively certain that this will do much more than any possible suggestion that you might have. Additionally, any suggestion that you might have can probably be combined with people being responsible for their own costs/grades.

I understand that a complete individual cost responsibility doesn't work for health care because we do want people who need care, but can't afford that care, to be able to get it. I am just suggesting that we make people responsible for themselves as much as possible. A high deductible plan does this. Everyone is responsible for themselves, but only up to a certain point. We recognize the necessity of some cost sharing.

This is how that would work with those other analogies.
Applebees: The price of everyone's entree's would be shared, but if someone chooses to buy drinks, appetizers, or desserts, the individual would pay themselves.
Grades: 50% of the cost will be based upon individual effort and 50% of the grade is based upon the class project.
Health Care: Everyone is responsible for their own costs. All costs above $X are shared.

but the object is the same: to put a value on good health for its own sake.
Why should we be putting a value on that? I mean that it is certainly something that I value. It doesn't have to be a value that you have. If you care more about sitting around eating bonbons and watching tv, why does that need to be an issue for everybody else? The object is to lower medical expenses. If the bill is being shared equally, valuing good health can very easily mean a huge increase in medical expenses. If someone else is footing the bill, why would you not get every single preventive medical measure done? You certainly would have zero incentive to do any cost/benefit analysis.

Your analogies would be appropriate if our actions only affected ourselves and not others. That isn't true for healthcare. Take employer health coverage. The plans I've participated in have had the same premiums regardless of age or health condition. Premiums might or might not vary based on member, member + spouse, and family coverage. How do employers attempt to control costs without loss of benefits? One method is to develop employee wellness programs and encourage participation in those programs. Although incentives, financial and otherwise, can be offered for employee participation, i contend that most people would rather be in good health than in poor health and are thus receptive to education.

Health education isn't just the province of employers. I've seen clinics offer classes and seminars that focus on preventive care, as well as palliative care.


You're talking about pre-illness. We're talking about post-diagnosis. They aren't the same thing!



In case you're lost allow me to explain. You're thinking about insurance costs and wellness programs from the perspective of non diagnosed people being incentivized to lower their risk. Admittedly as that stands the affects of that aren't that pronounced. What we're talking about is what happens after you get diagnosed. What do you do then? You immediately rush for 2 things quality and quantity and cost doesn't even enter into your mind because you're for the most part not paying for it, a 3rd party is(insurance company, your employer, or government entity is). We're trying to talk about how to get people to factor cost into their mind so that they don't spend other peoples money recklessly. Get it?

Given this it is actually he is who is talking about how people's actions affect others and it's you who isn't.

Well, at least I now understand your frustration. You are focusing on costs of treatment rather than prevention. Too bad you felt the need to patronize rather than explain. I think that preventive care is Crucial in lowering healthcare costs, but if you don't want to have that conversation, fine.

You've used the term "overutilization" a number of times. You and BrodyInsurance seem to put most of the onus for this on the patient, but is this really justified? I previously linked to a white paper discussing the huge amount of waste in our healthcare system. Included was a discussion of overutilization. Did you read it? Here's another link: http://www.managedcaremag.com/archives/0912/0912.utilization.htm...

From the above link:

Misuse and overuse run from simple antibiotics to sophisticated surgeries. More than $58 billion is spent on inappropriate drugs, such as antibiotics for upper respiratory infections that do not respond to medication, according to the institute report. About $21 billion is spent treating nonurgent cases in the emergency department, where physicians rely more on duplicative and costly tests because they are unfamiliar with their patients’ histories.

The largest potential area for savings — up to $600 billion a year — is the variation in hospital procedures such as the number of Caesarean sections and coronary bypass surgeries performed. Vaginal delivery is far safer than a C-section, and prescription medications can stabilize many heart patients without dangerous surgical complications, Rosof told the Post. Less invasive and risky alternatives are also less expensive.

“We will eliminate a lot of harm that comes from the overuse and inappropriate use and misuse of medical interventions,” he said. “This is not about rationing. This is about practicing evidence-based medicine.”

The root causes of each key finding were considered in the NEHI report, yielding five systemic issues requiring further consideration:

*Lack of compliance with clinical guidelines, raising issues of potential shortcomings in physician decision making
*Variation in the intensity of clinical care, suggesting a lack of evidence-based decisions
*Limited adoption of information technology in areas such as decision support and care coordination
*Underuse of cost-effective diagnostic tests
*Failure of the primary care system to meet access needs


Just to take one patient example, reducing unnecessary emergency room visits, a $21 billion annual expense.. My plan already has an incentive for that: ER visits have a $100 co-pay, visits to a doctor at my clinic have a $10 co-pay. As to whether patients drive requests for expendpsive, unnecessary tests and procedures, here's an insightful quote from an NY Times article: http://www.nytimes.com/2010/03/30/health/30use.html

Doctors often blame patients for demanding useless care, but many also concede that patients often have too little knowledge or power to say no to tests or treatments. The new law includes money for comparative effectiveness studies, and those can give guidance on which tests and treatments are better than others. But the law in no way forces patients or doctors to choose one test or treatment over another or to aim for the cheapest alternative. And it does nothing to change the reimbursement system, in which doctors often make more money if they order more tests, for instance.

You see raising healthcare costs for people as the solution to overutilization. I see an integrated approach, with doctors, patients, and health care providers working together to deliver the most efficient, effective healthcare solutions. Some organizations, such as the Mayo Clinic and Kaiser Permanente, have done just that.

I think that preventive care is Crucial in lowering healthcare costs, but if you don't want to have that conversation, fine.

Is that just a guess that you are having? I am asking because from what I've seen, the evidence doesn't actually back up this point of view.

Your analogies would be appropriate if our actions only affected ourselves and not others. That isn't true for healthcare. Take employer health coverage. The plans I've participated in have had the same premiums regardless of age or health condition. Premiums might or might not vary based on member, member + spouse, and family coverage. How do employers attempt to control costs without loss of benefits? One method is to develop employee wellness programs and encourage participation in those programs. Although incentives, financial and otherwise, can be offered for employee participation, i contend that most people would rather be in good health than in poor health and are thus receptive to education.

Health education isn't just the province of employers. I've seen clinics offer classes and seminars that focus on preventive care, as well as palliative care.


I have no problem with insurers or companies (for self-insured plans) offering wellness programs, etc. It is a completely different ballgame when insurance companies choose to do something vs. when they are forced to do something. They will choose to offer programs that are proven or they have reason to believe will lower medical costs. Instead, what we have is insurers being forced to cover so many things that don't lower the cost of care which increases insurance costs for everyone.

Employer paid guaranteed issue group insurance has a critical difference as compared to guaranteed individual coverage. With the group coverage, the young healthy person isn't paying to subsidize the older person. Therefore, the younger healthier person has no reason to not get coverage. With individual coverage, the young healthy person will be paying to subsidize the older person. It simply usually will not make economic sense to buy guaranteed issue coverage for healthy individuals.

We can probably agree that it is a stupid financial move for young healthy people to purchase guaranteed issue life and disability insurance, so why should it be different for health insurance?

"Guaranteed Issue" insurance only works under two circumstances. 1)Coverage is mandatory or a 3rd party is paying the premium 2)Coverage is optional, but it is priced so that only unhealthy people will buy it.

That is why the CLASS Act part of Obamacare had to be dumped. And, it is very likely why individual coverage is going to fail under Obamacare. It only makes sense that it will skew towards the unhealthy and those who will have their premiums subsidized. The more that it skews, the more that healthy people won't participate.

glxpass said:   Well, at least I now understand your frustration. You are focusing on costs of treatment rather than prevention. Too bad you felt the need to patronize rather than explain. I think that preventive care is Crucial in lowering healthcare costs, but if you don't want to have that conversation, fine.

You've used the term "overutilization" a number of times. You and BrodyInsurance seem to put most of the onus for this on the patient, but is this really justified? I previously linked to a white paper discussing the huge amount of waste in our healthcare system. Included was a discussion of overutilization. Did you read it? Here's another kink: http://www.managedcaremag.com/archives/0912/0912.utilization.htm...

From the above link:

Misuse and overuse run from simple antibiotics to sophisticated surgeries. More than $58 billion is spent on inappropriate drugs, such as antibiotics for upper respiratory infections that do not respond to medication, according to the institute report. About $21 billion is spent treating nonurgent cases in the emergency department, where physicians rely more on duplicative and costly tests because they are unfamiliar with their patients’ histories.

The largest potential area for savings — up to $600 billion a year — is the variation in hospital procedures such as the number of Caesarean sections and coronary bypass surgeries performed. Vaginal delivery is far safer than a C-section, and prescription medications can stabilize many heart patients without dangerous surgical complications, Rosof told the Post. Less invasive and risky alternatives are also less expensive.

“We will eliminate a lot of harm that comes from the overuse and inappropriate use and misuse of medical interventions,” he said. “This is not about rationing. This is about practicing evidence-based medicine.”

The root causes of each key finding were considered in the NEHI report, yielding five systemic issues requiring further consideration:

*Lack of compliance with clinical guidelines, raising issues of potential shortcomings in physician decision making
*Variation in the intensity of clinical care, suggesting a lack of evidence-based decisions
*Limited adoption of information technology in areas such as decision support and care coordination
*Underuse of cost-effective diagnostic tests
*Failure of the primary care system to meet access needs


Just to take one patient example, reducing unnecessary emergency room visits, a $21 billion annual expense.. My plan already has an incentive for that: ER visits have a $100 co-pay, visits to a doctor at my clinic have a $10 co-pay. As to whether patients drive requests for expendpsive, unnecessary tests and procedures, here's an insightful quote from an NY Times article: http://www.nytimes.com/2010/03/30/health/30use.html

Doctors often blame patients for demanding useless care, but many also concede that patients often have too little knowledge or power to say no to tests or treatments. The new law includes money for comparative effectiveness studies, and those can give guidance on which tests and treatments are better than others. But the law in no way forces patients or doctors to choose one test or treatment over another or to aim for the cheapest alternative. And it does nothing to change the reimbursement system, in which doctors often make more money if they order more tests, for instance.

You see raising healthcare costs for people as the solution to overutilization. I see an integrated approach, with doctors, patients, and health care providers working together to deliver the most efficient, effective healthcare solutions. Some organizations, such as the Mayo Clinic and Kaiser Permanente, have done just that.


My intent wasn't to patronize. I didn't see how it was possible for you to not understand what we were saying so if what I came off patronizing my apologies.

I agree with a mixed approach, but I need to ask whether you actually do. The reason why I ask is that you say your in favor of an 'integrated approach' yet your idea is to lower the already low deductibles and co-pays to a de minimus co-pay amount of $10 and $100. That basically renders costs essentially free for all participants in terms of what they'll actually have to chip in. So how can you say that is 'balanced'?

Okay, if you actually think that is needed, I say fine, but then you provide me some other method to encourage responsible spending by those that are receiving healthcare paid for by someone else.

And if you think that you can put it all onto the doctors you're kidding yourself. I benefit from having people close to me that work in different areas of healthcare. My entire extended family is basically split up between healthcare and finance. There is basically no one in my family that works outside of those 2 industries. One of them, my uncle, is a high end specialist. He makes probably $600k a year and could probably make $800k a year if recommending treatments that had the highest reimbursement rate. He doesn't do that because he doesn't care all he is after is producing the best outcomes for patients. He doesn't concern himself with what a lot of his recommendations cost and doesn't care because he wants *his* patients do well. He's not paid to find value for insurance companies, he believes his only concern should be focused on providing best outcomes. Now he has in the past suggested equal outcome treatments to patients that had a lower cost. What did the patients do? Every single time the patient chose the higher cost option. Why? Because it's not their money. He said you give up on even trying to bring it up after a while.

Now that story is typical of just about every doctor you meet. Once when a patient crosses their deductible they don't care anymore. The doctors don't pay attention to the costs of the prescriptions they prescribe. They don't even think about the costs of a specialist that they might refer. And that is generally speaking typical of practically every provider of any good or service anywhere not just healthcare. The provider is focused on outcome and the buyer should be focused on receiving value(quality/cost). But if you remove cost as a denominator from that equation you then have 2 people(the buyer and the seller) both focused on quality and nobody is focused on cost. And under that situation of unlimited demand it's not a surprise that more costs explode.


Now some of the best ideas I've come across is how do you deal with this problem in a way that still allows the individual to be able to get quality treatment if they need it and causes them to feel responsible for the money that is being spent. So seriously if you are truly after an 'integrated approach' than please show me ideas of where this responsibility is going to come from when you simultaneously decrease deductibles and co-pays. I mean give something at least here.

By the way you want to know the real reason why doctors don't give 2 $hit's about finding cost value in treatments for their patients? It's because they aren't there to find value for insurance companies. If it was their own patients money(and often times GPs are good about this because increasingly more it is the patients money) many of them would try to direct things to cheaper options. But when it comes to an insurance company or the government they know that every other doctor is billing the system to give their patients the best and they aren't going to be the one doctor to stop that(and potentially decrease outcomes marginally for their own patients) when they are insignificant enough to make a difference on national premiums anyway.

Just the same way that you don't care about providing value to insurance companies the doctors don't either. But behind that isn't just some company it's premium paying Americans all across this country that get stuck with the bill.

Just a single data point on the overutilization piece of the discussion. I had treatment for a disease and the follow up options were: a) several months of expensive care and b) wait & watch.

The long-term outcome for (a) & (b) were the same. The 'advantage' of (a) is that it reduces the risk of a relapse from 15-20% to about 1%. However, in case of a relapse, treatment is 99% effective.

I looked at this and thought that I'd rather take the 80-85% chance that I never had to get any more treatment since even if a relapse occurred, the treatment was just as effective.

Every medical professional involved in my care pushed option (a) which was 10x more expensive than option (b). I went to get a second opinion and that doctor thought that my approach was perfectly reasonable and that's what I did. Relapse did not occur and I'm glad I didn't go through the unnecessary treatment.

BostonOne said:   Just a single data point on the overutilization piece of the discussion. I had treatment for a disease and the follow up options were: a) several months of expensive care and b) wait & watch.

The long-term outcome for (a) & (b) were the same. The 'advantage' of (a) is that it reduces the risk of a relapse from 15-20% to about 1%. However, in case of a relapse, treatment is 99% effective.

I looked at this and thought that I'd rather take the 80-85% chance that I never had to get any more treatment since even if a relapse occurred, the treatment was just as effective.

Every medical professional involved in my care pushed option (a) which was 10x more expensive than option (b). I went to get a second opinion and that doctor thought that my approach was perfectly reasonable and that's what I did. Relapse did not occur and I'm glad I didn't go through the unnecessary treatment.


You're response is atypical. Most people would have done the opposite even without a doctor suggesting it.

glxpass, should I take the silence as meaning that you are having difficulties finding solutions that encourage financial responsibility of patients towards cost or should I take it as you not wanting to try preferring to ignore the issue?

dshibb - I like the idea of a high deductible plan that is refundable for low income households. However, in my experience, most low income households would have trouble with the cash flow for any meaningful amount of time (weeks, months, certainly once a year at tax-time would be a problem). What's the approach there? Obviously, if it's instant or paid for, there's no penalty for overuse.

BostonOne said:   dshibb - I like the idea of a high deductible plan that is refundable for low income households. However, in my experience, most low income households would have trouble with the cash flow for any meaningful amount of time (weeks, months, certainly once a year at tax-time would be a problem). What's the approach there? Obviously, if it's instant or paid for, there's no penalty for overuse.

Define what you mean by refundable and I'll throw out whatever ideas I can come up with.

dshibb said:   BostonOne said:   dshibb - I like the idea of a high deductible plan that is refundable for low income households. However, in my experience, most low income households would have trouble with the cash flow for any meaningful amount of time (weeks, months, certainly once a year at tax-time would be a problem). What's the approach there? Obviously, if it's instant or paid for, there's no penalty for overuse.

Define what you mean by refundable and I'll throw out whatever ideas I can come up with.
I had suggested a refundable tax credit that would make the after tax cost of a very HDHP "free" after taxes. People who didn't owe federal income taxes would be eligible for a tax refund equal to the cost of the policy. BostonOne is concerned that very poor people wouldn't have the cash flow to buy a policy and wait until tax time to be reimbursed. For people whose income is too high for Medicaid, one alternative would be vouchers issued by the government that would cover the cost of a VHDHP.

Let's say there was a HDHP that included some amount of "free" primary/preventive care. And let's say the deductible was $5K. Folks making even up to 3x the poverty guidelines (19K for a family of 3 in 2012) might find the $5K difficult to manage. So, let's say that 100% of this was refundable for folks at 1x the poverty guideline and below, 75% for 1x-2x and 50% for 2x-3x. That amount would be refundable to the household. If you make the refund instant, similar to an FSA debit card, then there is no penalty for those that are getting 100% refundable. Maybe that's the price you have to pay to prevent people from avoiding necessary care.

A few weeks ago I had a physical. Doctor's office sent standard set of bloog, urine, stool, saliva, etc, tests to the lab. A few days later, I find a claim from Sunset Labs or whatever. Billed amount: $1245 or something like that. Insurance company pays around $25. The rest? Well, magically disappears.

I felt like I was on a post-christmast sale at a discount store like Marshalls, with a 80% of coupon on already 80% reduced merchandise of prices that are 50% off department store prices.

(1-50%) * ( 1- 80%) * ( 1 - 80%) = one hekuva discount.

Now, what are they doing, billing $1245 for a test that is only going to fetch them $25 or so from insurance? Are they stupid or something?

BostonOne said:   Let's say there was a HDHP that included some amount of "free" primary/preventive care. And let's say the deductible was $5K. Folks making even up to 3x the poverty guidelines (19K for a family of 3 in 2012) might find the $5K difficult to manage. So, let's say that 100% of this was refundable for folks at 1x the poverty guideline and below, 75% for 1x-2x and 50% for 2x-3x. That amount would be refundable to the household. If you make the refund instant, similar to an FSA debit card, then there is no penalty for those that are getting 100% refundable. Maybe that's the price you have to pay to prevent people from avoiding necessary care.

Okay so if I understand you correctly(and what I initially thought, but wasn't positive) what you're saying is that patient spends money out of pocket up to the deductible and then gets refunded/reimbursed at the end of the year?

Basically the intention of course being to have the patient care about the cost because they're watching the dollars fly out of their own pocket, but for them to be okay in the end because they'll get it back at some date in the future?

If that's what you're saying I'll first say that I do like where your head is at. That is the type of thinking that I think could come to some interesting solutions. I would make the wager that the level of responsibility people took on would actually work inversely to their access to liquidity. What I mean is that I think you would have the dichotomy where the person with limited access to liquidity would be focused on finding value, but he also would have trouble with the means. And the person that had no problem with liquidity(let's say had $10k in the bank--meaning they only temporarily parted with $5k) would act like they weren't paying for it(which is technically true).

You could call your plan by 2 names. A HDHP with a refundable deductible in the future or you could call it a full coverage plan with delayed reimbursement.

Also, you would likely see a lot of behavior of people waiting to the end of the year to seek treatment so that they could shorten the length of time for which they parted with their liquidity and more quickly received their reimbursement.

So I like the way you're thinking, but I think you need and think a little more on it because not only does it potentially pose liquidity problems for the poor, but also might not have the attended affect if that impoverished person does have the liquidity. I'll do some thinking on it here and see if I can think of some other ways to mess with this idea a bit and see what I can come up with.

If instead you mean this from the perspective of *the policy itself* being *tax* refundable(like Ryeny3 suggested) than I'm sorry that was the other possibility I thought you may have getting at, and you are referring to the mismatch of upfront premium costs vs. future tax credit than there are quite a few ways to deal with that which I can share if needed.

I'll give you some other thought that I haven't delved into much on the subject.

Is there any non monetary costs that a poorer individual could incur if when they utilize healthcare? If there is something else that they value that they can forego when they utilize healthcare costs than maybe that is something that can be a good compromise between making sure they have the means for healthcare, but an incentive to keep costs under control.

dshibb said:   glxpass, should I take the silence as meaning that you are having difficulties finding solutions that encourage financial responsibility of patients towards cost or should I take it as you not wanting to try preferring to ignore the issue?
Please don't assume my silence means acquiescence. I've linked to various sources that discuss overutilization and discuss the roles doctors play in the process. I ask you again: Did you read them? Besides anecdotal evidence supplied by your relatives in the healthcare industry, I've no idea what research you've done on this topic. IIRC, you say your specialist uncle has laid out treatment options A and B, citing the costs of both, saying they were equally effective, asking the patient to choose which option, and that the patient has always chosen the most expensive option.

IME, I've never had a specialist give me costs of different treatment options and had me choose on that basis. Sometimes there have been no options; treatment follows what I presume are best practices for the situation. In other cases, my choices have taken into consideration success rate, safety, length of time for treatment, details of the treatment, etc. Now you say I should also factor in cost of the treatment, because if I don't, I'm fiscally irresponsible since I don't have skin in the game. The fact is these are all variables. I'd contend rarely if ever, the only difference in factors is cost. Higher cost of a specific treatment option doesn't necessarily imply that I should pay more to use that option. One reason is that we aren't identical clones of each other. What might be effective and efficiefor you isn't necessarily the same for me and might cost more for me than you.

Your determination to frame treatment costs as a patient responsibility issue.and to address this by raising deductibles is, I think, a false start. To your credit though, you now mention a mixed approach. As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience. Yet if a doctor tells me I need X procedure or test done and persuades me that it's in my best interest to have it done, then so be it. Why should I put.additional funds into the treatment?

I see an integrated approach as one that delivers the best solution for me, based on time, resources, and efficacy. I don't need and certainly don't expect others to pay for what I'd call boutique medivpcal services, but as I said in another post, I expect to have adequate healthcare that takes into account my situation. The same goes for other patients. And, yes, I'm willing and able to pay higher premiums, even if it means subsidizing others. That's what a civilized society does, IMO. Does this preclude addressing healthcare cost issues? Of course not. Although I'm willing to subsidize others less fortunate than I, it's in my best interest to have a lower cost.

As I've said previously, we need to question whether the pay-for-service model is the best way to approach healthcare.

brettdoyle said:   

One of the other hilarious things about medical equipment is that the manufacturers drastically inflate their prices when they sell to the United States. So that GE or Siemens MRI machine is marketed and sold for perhaps $1.5 million in India or the UK, but then they turn around and sell the same machine for $10 million in the US market because they know we are suckers.

This also happens with college text books(another industry broken by government)... when I did my MBA, I would get the ISBN and buy the "international edition" text books that only cost $30 that were usually shipped overnight from Singapore... but all of my classmates went to the campus bookstore often paid $250 for the same book. The international edition usually had "NOT FOR SALE IN THE UNITED STATES" in big letters to prevent merchants from selling it and perpetuating the scam.


I had no idea that they did that with medical equipment ..just a shame. True about the textbooks.. when I first heard how much a book cost here.. I just added that to my growing list of surprises. For $250 it better have been a gold plated book.

It seems like the government just doesn't want its citizens to be an educated, healthy and progressive lot.

No wonder junk food is so cheap

glxpass said:   As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience.

It would be a big, big mistake to extrapolate your own disinclination to misuse health care to society in general. There are tons of reasons why people inappropriately utilize health care. Starter list: addiction, loneliness, neurosis, homelessness, home repairs, Munchausen's, bad weather, power outages, unwillingness to pay for an office visit at 4PM when you can get taken care of "free" in the ED at 4AM, unwillingness to pay for meds at the pharmacy when you can score them for "free" in the hospital, unwillingness to pay to take the bus across town when the ambulance will do it for "free"....I am sad to say that I have seen examples of all of these behaviors, including the last one.

glxpass said:   dshibb said:   glxpass, should I take the silence as meaning that you are having difficulties finding solutions that encourage financial responsibility of patients towards cost or should I take it as you not wanting to try preferring to ignore the issue?
Please don't assume my silence means acquiescence. I've linked to various sources that discuss overutilization and discuss the roles doctors play in the process. I ask you again: Did you read them? Besides anecdotal evidence supplied by your relatives in the healthcare industry, I've no idea what research you've done on this topic. IIRC, you say your specialist uncle has laid out treatment options A and B, citing the costs of both, saying they were equally effective, asking the patient to choose which option, and that the patient has always chosen the most expensive option.

IME, I've never had a specialist give me costs of different treatment options and had me choose on that basis. Sometimes there have been no options; treatment follows what I presume are best practices for the situation. In other cases, my choices have taken into consideration success rate, safety, length of time for treatment, details of the treatment, etc. Now you say I should also factor in cost of the treatment, because if I don't, I'm fiscally irresponsible since I don't have skin in the game. The fact is these are all variables. I'd contend rarely if ever, the only difference in factors is cost. Higher cost of a specific treatment option doesn't necessarily imply that I should pay more to use that option. One reason is that we aren't identical clones of each other. What might be effective and efficiefor you isn't necessarily the same for me and might cost more for me than you.

Your determination to frame treatment costs as a patient responsibility issue.and to address this by raising deductibles is, I think, a false start. To your credit though, you now mention a mixed approach. As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience. Yet if a doctor tells me I need X procedure or test done and persuades me that it's in my best interest to have it done, then so be it. Why should I put.additional funds into the treatment?

I see an integrated approach as one that delivers the best solution for me, based on time, resources, and efficacy. I don't need and certainly don't expect others to pay for what I'd call boutique medivpcal services, but as I said in another post, I expect to have adequate healthcare that takes into account my situation. The same goes for other patients. And, yes, I'm willing and able to pay higher premiums, even if it means subsidizing others. That's what a civilized society does, IMO. Does this preclude addressing healthcare cost issues? Of course not. Although I'm willing to subsidize others less fortunate than I, it's in my best interest to have a lower cost.

As I've said previously, we need to question whether the pay-for-service model is the best way to approach healthcare.


A) Yes I read your links a while ago. They adequately address the problem and then proceed to drop the onus on the providers to solve it. There is no possible way you could create a method to cost/benefit analysis the entire healthcare industry. It's impossible and too complicated. There may be sensible options available there, but new treatments/options/etc. will pop up faster than you can address them. You need patient involvement as part of the mix.
B) I have spent a lot of time researching the issues involved. Do I sound like someone who doesn't know what he's talking about?
C) Not a big deal, but there is a tone to your re-framing of my uncles words that implies an outline format to his method of communication that I didn't intend to convey.
D) Probably the reason why you haven't had that happen is because most specialists A) Don't know/Don't Care B) Have grown accustomed to patients picking whatever option seems to be marginally better when they're no longer paying for it and they've given up even mentioning relative costs when giving options.
E) Yes I see a problem with a person not caring about the cost. You might say 'these are all variables', but you actively try to limit any practical focus on that one. Someone in my position tends to be skeptical when a person gives lip service to a variable and how it matters, but then proceeds to offer zero to address it.
F) Actually go back and read my posts specifically the one I went out on a limb on. You should notice that I was genuinely curious about your thoughts for addressing the issue and didn't limit it to deductibles. I'm not wedded to the idea of deductibles, I just haven't yet come up with a better alternative. I was hoping you might provide some other alternatives which you have not.
G) I never even implicitly suggested that you didn't need a mixed approach. I made clear that one of those things has to involve more patient responsibility over costs. I would argue it is you that is trying to avoid any resemblance of a mixed approach because it is you that prefers to ignore the topic of patient responsibility for the costs payed on their behalf.
H) As a patient you might not find healthcare services enjoyable, but if you get diagnosed you are going to select every healthcare service you think you can benefit from and you are going to pick the highest quality option every time. As long as that happens costs will continue to rise. It's not a simple question of the current amount being expensive. If it was going to stay static you may have a reasonable point. The problem is that it wont stay static. It will continue to increase each and every year until the industry has gobbled up so much cash and so much GDP that it literally stretches everything to the breaking point. Then it's going to be the sick patients that are going to be hurt the most.
I) You ignore human nature. The doctor is going to recommend to you the best outcome treatment(even if it's only marginally better than a substantially cheaper option). You can put all the onus on them to find value maybe based on some outcome/cost formula they maintain in their head, but honestly in any other service it would be the customer that would be weighing that based on their own perceptions of value and expense. We've lost that in healthcare and now you want to put 100% of that onto the Doctors and hospitals and it will never happen. Struggling hospitals have enough on their plate and putting themselves more in the red to save insurance company or government money is not one of those things they'll ever be persuaded into doing.
J) This:
glxpass said: I see an integrated approach as one that delivers the best solution for me, based on time, resources, and efficacy.
Means zero! It's just a vague cop out designed to hide the fact that you don't have any practical ideas or solutions at all. You don't want an integrated approach because you refuse to provide anything that could cause patients to feel more responsible for the costs spent on their behalf.
K) Practically nobody has a problem with subsidizing the sick through premiums otherwise they would never buy insurance. The problem people have is that their premiums rise by a lot every single year. You may be willing to pay higher premiums now, but if you actually did foot the bill for your insurance premiums on an individual basis eventually at the rate we're going you'll hit your breaking point as well. If we could be guaranteed the insurance premiums only went up at the rate of overall inflation from now on people may be okay with it. The problem is that when wage inflation goes up by a smaller percentage than healthcare inflation that is unsustainable.
L) Obviously it's in your best interests to have lower costs, but only in a world where you can eat your cake too. You want people to have *limitless* demand of healthcare services paid for by someone else and then say you want lower costs as well. That isn't thinking of solutions that is living a fairy tale.
M) I do think we should look at the fee for service model and I have been behind numerous pilot projects that sought to take a look at that, but as long as patients demand highest quality treatment other reimbursement methods will not abate the problem.


So I'll repeat it again. I'm not wedded to deductibles and co-pays. It wasn't my intention to try to debate whether those are effective. It was my intention to see what ideas you had to encourage patient responsibility and you still have provided zero!(even though you say your after an 'integrated approach')

geo123 said:   rpi1967 said:   That is the rationale for different pAyments amounts,but if your ekg is performed as an outpatient an ordered by a hospital employed physician then the bill will be higher, perhaps twice as high than solo practitioner.No, that's incorrect. If your ekg is performed at a doctor's office, the Medicare reimbursement rate is going to be the same regardless of who the doctor works for (a private practice or a hospital). If the same patient goes to the hospital to get it done, the Medicare reimbursement rate is going to be (or at least could be, as it'll depend on several other things) higher, because now he is paying not just for the ekg but for the higher overhead that it takes to run a hospital, additional equipment that is there, etc... If the same ekg is ordered on the same patient at an ER, the Medicare reimbursement is going to be even higher, because now you are paying for even higher overhead costs.

Again, the above will be the same regardless of who the doctor works for. A hospital doesn't get to purchase a medical clinic and suddenly start collecting higher Medicare reimbursements for the same exact things.


They can and will close down services in the clinic so that services the hospital performs can be more "efficiently provided in the hospital" The hospital will use the hospital provider number get higher reimbursements. Otherwise they could not dream of buying practices and guarantee physician incomes in the face of declining reimbursements as outlined in WSJl.

Also the hospital could buy the clinic building and rename it as a hospital facility.

dshibb said:   BostonOne said:   Let's say there was a HDHP that included some amount of "free" primary/preventive care. And let's say the deductible was $5K. Folks making even up to 3x the poverty guidelines (19K for a family of 3 in 2012) might find the $5K difficult to manage. So, let's say that 100% of this was refundable for folks at 1x the poverty guideline and below, 75% for 1x-2x and 50% for 2x-3x. That amount would be refundable to the household. If you make the refund instant, similar to an FSA debit card, then there is no penalty for those that are getting 100% refundable. Maybe that's the price you have to pay to prevent people from avoiding necessary care.

Okay so if I understand you correctly(and what I initially thought, but wasn't positive) what you're saying is that patient spends money out of pocket up to the deductible and then gets refunded/reimbursed at the end of the year?

Basically the intention of course being to have the patient care about the cost because they're watching the dollars fly out of their own pocket, but for them to be okay in the end because they'll get it back at some date in the future?

If that's what you're saying I'll first say that I do like where your head is at. That is the type of thinking that I think could come to some interesting solutions. I would make the wager that the level of responsibility people took on would actually work inversely to their access to liquidity. What I mean is that I think you would have the dichotomy where the person with limited access to liquidity would be focused on finding value, but he also would have trouble with the means. And the person that had no problem with liquidity(let's say had $10k in the bank--meaning they only temporarily parted with $5k) would act like they weren't paying for it(which is technically true).

You could call your plan by 2 names. A HDHP with a refundable deductible in the future or you could call it a full coverage plan with delayed reimbursement.

Also, you would likely see a lot of behavior of people waiting to the end of the year to seek treatment so that they could shorten the length of time for which they parted with their liquidity and more quickly received their reimbursement.

So I like the way you're thinking, but I think you need and think a little more on it because not only does it potentially pose liquidity problems for the poor, but also might not have the attended affect if that impoverished person does have the liquidity. I'll do some thinking on it here and see if I can think of some other ways to mess with this idea a bit and see what I can come up with.

If instead you mean this from the perspective of *the policy itself* being *tax* refundable(like Ryeny3 suggested) than I'm sorry that was the other possibility I thought you may have getting at, and you are referring to the mismatch of upfront premium costs vs. future tax credit than there are quite a few ways to deal with that which I can share if needed.

I was thinking more of an FSA-style reimbursement, which would take days to weeks. A yearly reimbursement or tax credit seems like a high cash flow burden for many. It's not a huge disincentive if you know you're getting paid back soon, but it's a modest disincentive. And, for those with the highest reimbursement, the cash flow disincentive will likely be greatest, even over a short period of time.

BostonOne said:   dshibb said:   BostonOne said:   Let's say there was a HDHP that included some amount of "free" primary/preventive care. And let's say the deductible was $5K. Folks making even up to 3x the poverty guidelines (19K for a family of 3 in 2012) might find the $5K difficult to manage. So, let's say that 100% of this was refundable for folks at 1x the poverty guideline and below, 75% for 1x-2x and 50% for 2x-3x. That amount would be refundable to the household. If you make the refund instant, similar to an FSA debit card, then there is no penalty for those that are getting 100% refundable. Maybe that's the price you have to pay to prevent people from avoiding necessary care.

Okay so if I understand you correctly(and what I initially thought, but wasn't positive) what you're saying is that patient spends money out of pocket up to the deductible and then gets refunded/reimbursed at the end of the year?

Basically the intention of course being to have the patient care about the cost because they're watching the dollars fly out of their own pocket, but for them to be okay in the end because they'll get it back at some date in the future?

If that's what you're saying I'll first say that I do like where your head is at. That is the type of thinking that I think could come to some interesting solutions. I would make the wager that the level of responsibility people took on would actually work inversely to their access to liquidity. What I mean is that I think you would have the dichotomy where the person with limited access to liquidity would be focused on finding value, but he also would have trouble with the means. And the person that had no problem with liquidity(let's say had $10k in the bank--meaning they only temporarily parted with $5k) would act like they weren't paying for it(which is technically true).

You could call your plan by 2 names. A HDHP with a refundable deductible in the future or you could call it a full coverage plan with delayed reimbursement.

Also, you would likely see a lot of behavior of people waiting to the end of the year to seek treatment so that they could shorten the length of time for which they parted with their liquidity and more quickly received their reimbursement.

So I like the way you're thinking, but I think you need and think a little more on it because not only does it potentially pose liquidity problems for the poor, but also might not have the attended affect if that impoverished person does have the liquidity. I'll do some thinking on it here and see if I can think of some other ways to mess with this idea a bit and see what I can come up with.

If instead you mean this from the perspective of *the policy itself* being *tax* refundable(like Ryeny3 suggested) than I'm sorry that was the other possibility I thought you may have getting at, and you are referring to the mismatch of upfront premium costs vs. future tax credit than there are quite a few ways to deal with that which I can share if needed.

I was thinking more of an FSA-style reimbursement, which would take days to weeks. A yearly reimbursement or tax credit seems like a high cash flow burden for many. It's not a huge disincentive if you know you're getting paid back soon, but it's a modest disincentive. And, for those with the highest reimbursement, the cash flow disincentive will likely be greatest, even over a short period of time.


It's probably a very modest step in the right direction. Hospitals will make sure there is no liquidity issue there by agreeing to delay payment/finance over the period. So there should be zero concern of any liquidity issues preventing anyone from anything.

When I suggested a very HDHP plan, I was assuming that Medicaid would continue to serve the poor. One alternative to the traditional Medicaid model is a HDHP with co-pays based on income bands. Using BostonOne's example, people at 1X the poverty line would have co-pays at $0, 1x to 2x at 25%, and 2x-3x at 50%. Although copays based on income and an FSA accomplish the same thing, the copay skips the "rebate" process.



Updated.

dshibb said:   ....
D) Probably the reason why you haven't had that happen is because most specialists A) Don't know/Don't Care B) Have grown accustomed to patients picking whatever option seems to be marginally better when they're no longer paying for it and they've given up even mentioning relative costs when giving options.
E) Yes I see a problem with a person not caring about the cost. You might say 'these are all variables', but you actively try to limit any practical focus on that one. Someone in my position tends to be skeptical when a person gives lip service to a variable and how it matters, but then proceeds to offer zero to address it.
F) Actually go back and read my posts specifically the one I went out on a limb on. You should notice that I was genuinely curious about your thoughts for addressing the issue and didn't limit it to deductibles. I'm not wedded to the idea of deductibles, I just haven't yet come up with a better alternative. I was hoping you might provide some other alternatives which you have not.
G) I never even implicitly suggested that you didn't need a mixed approach. I made clear that one of those things has to involve more patient responsibility over costs. I would argue it is you that is trying to avoid any resemblance of a mixed approach because it is you that prefers to ignore the topic of patient responsibility for the costs payed on their behalf.
H) As a patient you might not find healthcare services enjoyable, but if you get diagnosed you are going to select every healthcare service you think you can benefit from and you are going to pick the highest quality option every time. As long as that happens costs will continue to rise. It's not a simple question of the current amount being expensive. If it was going to stay static you may have a reasonable point. The problem is that it wont stay static. It will continue to increase each and every year until the industry has gobbled up so much cash and so much GDP that it literally stretches everything to the breaking point. Then it's going to be the sick patients that are going to be hurt the most.
I) You ignore human nature. The doctor is going to recommend to you the best outcome treatment(even if it's only marginally better than a substantially cheaper option). You can put all the onus on them to find value maybe based on some outcome/cost formula they maintain in their head, but honestly in any other service it would be the customer that would be weighing that based on their own perceptions of value and expense. We've lost that in healthcare and now you want to put 100% of that onto the Doctors and hospitals and it will never happen. Struggling hospitals have enough on their plate and putting themselves more in the red to save insurance company or government money is not one of those things they'll ever be persuaded into doing.
....
Most years, I visit a doctor's office 2x per year, once for a physical and once for a flu shot. Neither visit has a co-pay. If I paid an additional amount for a physical, I would go every three years instead of annually.

I exercise 350+ days a year and I have a resting pulse of about 50. A few years ago, I called my PCP's office and said I didn't want an EKG because I felt it was unnecessary for me to have one every year. I don't remember the details, but I believe I was told that I had to discuss this with my PCP and that I had to sign a scary sounding release acknowledging the risks. In the end, I decided it was easier to have the EKG since it didn't cost extra.

Each year, someone in my office calls to find out what tests are being covered during a physical. Last year, we found out that some of the blood tests and EKG's were no longer covered. When I went in for a physical, I told my PCP that I didn't want one because of the additional cost. My doctor said something like: "That's fine, since you don't really need one anyway."

I am sure that my doctor believes that there is some minimal benefit of an EKG to me. It's just that he apparently doesn't believe that the additional information it might provide to us are worth the out of pocket costs to me.

ryeny3 said:   When I suggested a very HDHP plan, I was assuming that Medicaid would continue to serve the poor. One alternative to the traditional Medicaid model is a HDHP with co-pays based on income bands. Using BostonOne's example, people at 1X the poverty line would have co-pays at $0, 1x to 2x at 75%, and 2x-3x at 75%. Although copays based on income and an FSA accomplish the same thing, the copay skips the "rebate" process.

Interesting! I assume you mean a lower percentage for 1x-2x than you do for 2x-3x.


You know I'll go ahead and share my ideas on the subject matter. Now again I'm not particularly wedded to them they're just what I've so far thought up as the best I've been able to come up with.


The first place I look is to what best practice is for those that are financially secure and then seek to re-duplicate that for those that aren't.

So how would the financially secure approach this from an ideal standpoint. They would have:
1) At least a decent sized cash or liquid invested position largely earmarked for deductibles and co-pays if tragedy was to strike. Let's say they probably have zero to worry about if that number is let's say around ~4 times their maximum out of pocket for a given year because if a chronic situation occurred they would have several years of self funding.
2) And they would also have reserves to pay health insurance premiums in the event that they lost work or received a drastic pay cut(went on disability for example at an amount substantially less than their current income).
3) They have a high deductible, high co-pay plan because if something were to happen to them they would have the means to pay for it.
4) I think we could safely say that if it was possible to duplicate that is in some fashion for the masses not only would we have a stable healthcare marketplace with costs contained, but also one where capacity to pay wouldn't be as much of an issue.

Now the problem with the HSA + HDHP today(even though it's a step in the right direction) is that people need excess discretionary funds in order to fund which means that it isn't beneficial to the poor. It's really only a cost containment mechanism on the overall market by influencing the behavior of the upper income half of the country. Furthermore, it requires voluntary responsible behavior of which the problem was never really located in the voluntarily responsible.

So instead how do you get to a point where every person in the country has first of all sufficient cash reserves to meet any and all deductibles and co-pays? Because if we can do that then we don't need to have 100% unlimited demand in any area of the marketplace. Well the best I've been able to come up with is to stratify the accounts based on the specific purpose(similar to how responsible people earmark money) and then make sure that the important ones are sufficient in size.

Let's say we gave every new born and child in the country $10k in a locked account(HSA if you want to call it that). We allow that account grow over 18(or whatever) years of their life and then at age it becomes available for use exclusively as a deductible and co-pay account. It'll probably be at least be $20k by then.
For poor people:
-The government continues to contribute a small amount of money annually into the same account on a sliding basis(probably in the neighborhood of a few hundred dollars a year)
-You then subject the max out of pocket deductible for poor people at a ratio of that account balance. So let's say it's 4 times.
-If they don't use it, it continues to grow.
-If they do use some of it then they have to contribute a percentage of their income to refill it back up(in addition to what the government contributes).
-You then say that at maybe $50k(indexed to healthcare inflation) and any amount that overflows that amount you can withdraw so they have an incentive to not waste the money inside of the account on unnecessary health expenses.

You would then have the traditional HSA as we see it now as a more flexible account overlaid on top. That would primarily be used by people that wanted to put money aside for higher healthcare deductibles yet and for people that wanted to have an account to pay distributions for health insurance premiums, etc.

Then implement a sliding scale voucher(or tax credit) to buy insurance up the a certain level of the poverty line. Don't try to standardize those plans people will pick what is best for them ***which will be high deductible/high co-pay because all of them will have the means to pay for those deductibles and co-pays***

Then you basically have 2 different solutions for the high risk people. Either state guarantee fund or the government back stops insurer losses beyond a certain point for certain health classes allowing for pricing to stay easily within reach for high risk individuals.

For me this would solve the moral question of making sure that every American had access to the cash needed to pay for care, but allowed people to take more responsibility for healthcare spending causing overutilization to fall and finally creating a positive cycle of declining costs and premiums in healthcare(progressively making the whole situation easier and easier to deal with).

DrDubious said:   glxpass said:   As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience.

It would be a big, big mistake to extrapolate your own disinclination to misuse health care to society in general. There are tons of reasons why people inappropriately utilize health care. Starter list: addiction, loneliness, neurosis, homelessness, home repairs, Munchausen's, bad weather, power outages, unwillingness to pay for an office visit at 4PM when you can get taken care of "free" in the ED at 4AM, unwillingness to pay for meds at the pharmacy when you can score them for "free" in the hospital, unwillingness to pay to take the bus across town when the ambulance will do it for "free"....I am sad to say that I have seen examples of all of these behaviors, including the last one.

I realize that there are people who abuse the current healthcare system and will do their best to do the same for any healthcare system. Some questions and thoughts:

* How prevalent is this and what portion of overutilization costs are attributable to patients abusing the system?

* If everyone has health insurance or is subject to paying a fine if they don't have insurance and require healthcare, and If medical records were available to all providers by looking up a UPI (universal patient identifier -- I know there are privacy concerns about this), could that be used to identify and figure out ways to mitigate the abuse?

* Regardless of patient intent, we need to reduce the frequency of ER visits and make ER visits less expensive. Ways to do this might include providing more access and increased pre-screening by one's PCP, expanding the number of urgent care clinics (which should be less costly than ERs and from which truly critical cases that need further treatment are referred to ERs), increased use of PA's (physician assistants, etc.

* I've already stated I've no problem with a higher co-pay for ER visits compared with primary care physician visits. The same goes for hospitalization.

glxpass said:   DrDubious said:   glxpass said:   As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience.

It would be a big, big mistake to extrapolate your own disinclination to misuse health care to society in general. There are tons of reasons why people inappropriately utilize health care. Starter list: addiction, loneliness, neurosis, homelessness, home repairs, Munchausen's, bad weather, power outages, unwillingness to pay for an office visit at 4PM when you can get taken care of "free" in the ED at 4AM, unwillingness to pay for meds at the pharmacy when you can score them for "free" in the hospital, unwillingness to pay to take the bus across town when the ambulance will do it for "free"....I am sad to say that I have seen examples of all of these behaviors, including the last one.

I realize that there are people who abuse the current healthcare system and will do their best to do the same for any healthcare system. Some questions and thoughts:

* How prevalent is this and what portion of overutilization costs are attributable to patients abusing the system?

* If everyone has health insurance or is subject to paying a fine if they don't have insurance and require healthcare, and If medical records were available to all providers by looking up a UPI (universal patient identifier -- I know there are privacy concerns about this), could that be used to identify and figure out ways to mitigate the abuse?

* Regardless of patient intent, we need to reduce the frequency of ER visits and make ER visits less expensive. Ways to do this might include providing more access and increased pre-screening by one's PCP, expanding the number of urgent care clinics (which should be less costly than ERs and from which truly critical cases that need further treatment are referred to ERs), increased use of PA's (physician assistants, etc.

* I've already stated I've no problem with a higher co-pay for ER visits compared with primary care physician visits. The same goes for hospitalization.



No you actually suggested that they be *reduced drastically* to $100 and $10 which basically makes them de minimis!

Have you come up with any other ideas yet on how to make the patients *want* to be more responsible to cost?

dshibb said:   glxpass said:   DrDubious said:   glxpass said:   As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience.

It would be a big, big mistake to extrapolate your own disinclination to misuse health care to society in general. There are tons of reasons why people inappropriately utilize health care. Starter list: addiction, loneliness, neurosis, homelessness, home repairs, Munchausen's, bad weather, power outages, unwillingness to pay for an office visit at 4PM when you can get taken care of "free" in the ED at 4AM, unwillingness to pay for meds at the pharmacy when you can score them for "free" in the hospital, unwillingness to pay to take the bus across town when the ambulance will do it for "free"....I am sad to say that I have seen examples of all of these behaviors, including the last one.

I realize that there are people who abuse the current healthcare system and will do their best to do the same for any healthcare system. Some questions and thoughts:

* How prevalent is this and what portion of overutilization costs are attributable to patients abusing the system?

* If everyone has health insurance or is subject to paying a fine if they don't have insurance and require healthcare, and If medical records were available to all providers by looking up a UPI (universal patient identifier -- I know there are privacy concerns about this), could that be used to identify and figure out ways to mitigate the abuse?

* Regardless of patient intent, we need to reduce the frequency of ER visits and make ER visits less expensive. Ways to do this might include providing more access and increased pre-screening by one's PCP, expanding the number of urgent care clinics (which should be less costly than ERs and from which truly critical cases that need further treatment are referred to ERs), increased use of PA's (physician assistants, etc.

* I've already stated I've no problem with a higher co-pay for ER visits compared with primary care physician visits. The same goes for hospitalization.



No you actually suggested that they be *reduced drastically* to $100 and $10 which basically makes them de minimis!

Have you come up with any other ideas yet on how to make the patients *want* to be more responsible to cost?

To you, $100 might seem trivial. To me, it's not. For "serial" ER visitors, I think even less so. Regardless, I think it's important to get to the root causes of overutilization by patients and figure out ways to solve the problem. I don't think financial disincentives are the way to do that, especially if it turns out that most of the healthcare abuse comes from those of relatively meager financial means. There are other ways for patients to take reponsibility for their healthcare.

Education is one route. Require patients to attend a "health awareness" class, which explains their health care alternatives, such as when to contact a PCP, when to go to urgent care, ER visit guidelines, etc. if the patient doesn't attend the class, then it might cst more to obtain ER services. This is just a basic idea, which would need much refining. My main point is that I believe that financial penalties alone aren't going to change behavior significantly.

I still maintain that doctors can play an important role in reducing overutilization. I feel this is necessary, even if it isn't sufficient to solve the problem. Remember that overutilization is just one reason for excessive healthcare costs.

glxpass said:   dshibb said:   glxpass said:   DrDubious said:   glxpass said:   As a patient, I'm already incentivized not to stay in the hospital any longer than I have to, not to go from one unnecessary doctor's appointment to another, not to visit the ER whenever I've a complaint that seems non-urgent, not to take any more prescriptions than I have to. While he co-pays can add up, the primary reason for my avoiding these things isn't their healthcare cost, it's because doing all this isn't a particularly pleasant experience.

It would be a big, big mistake to extrapolate your own disinclination to misuse health care to society in general. There are tons of reasons why people inappropriately utilize health care. Starter list: addiction, loneliness, neurosis, homelessness, home repairs, Munchausen's, bad weather, power outages, unwillingness to pay for an office visit at 4PM when you can get taken care of "free" in the ED at 4AM, unwillingness to pay for meds at the pharmacy when you can score them for "free" in the hospital, unwillingness to pay to take the bus across town when the ambulance will do it for "free"....I am sad to say that I have seen examples of all of these behaviors, including the last one.

I realize that there are people who abuse the current healthcare system and will do their best to do the same for any healthcare system. Some questions and thoughts:

* How prevalent is this and what portion of overutilization costs are attributable to patients abusing the system?

* If everyone has health insurance or is subject to paying a fine if they don't have insurance and require healthcare, and If medical records were available to all providers by looking up a UPI (universal patient identifier -- I know there are privacy concerns about this), could that be used to identify and figure out ways to mitigate the abuse?

* Regardless of patient intent, we need to reduce the frequency of ER visits and make ER visits less expensive. Ways to do this might include providing more access and increased pre-screening by one's PCP, expanding the number of urgent care clinics (which should be less costly than ERs and from which truly critical cases that need further treatment are referred to ERs), increased use of PA's (physician assistants, etc.

* I've already stated I've no problem with a higher co-pay for ER visits compared with primary care physician visits. The same goes for hospitalization.



No you actually suggested that they be *reduced drastically* to $100 and $10 which basically makes them de minimis!

Have you come up with any other ideas yet on how to make the patients *want* to be more responsible to cost?

To you, $100 might seem trivial. To me, it's not. For "serial" ER visitors, I think even less so. Regardless, I think it's important to get to the root causes of overutilization by patients and figure out ways to solve the problem. I don't think financial disincentives are the way to do that, especially if it turns out that most of the healthcare abuse comes from those of relatively meager financial means. There are other ways for patients to take reponsibility for their healthcare.

Education is one route. Require patients to attend a "health awareness" class, which explains their health care alternatives, such as when to contact a PCP, when to go to urgent care, ER visit guidelines, etc. if the patient doesn't attend the class, then it might cst more to obtain ER services. This is just a basic idea, which would need much refining. My main point is that I believe that financial penalties alone aren't going to change behavior significantly.

I still maintain that doctors can play an important role in reducing overutilization. I feel this is necessary, even if it isn't sufficient to solve the problem. Remember that overutilization is just one reason for excessive healthcare costs.


Come on! Really?

So you say you're after an 'integrated(read mixed) approach', but then say you want to drastically reduce patient responsibility from where it is today. That isn't mixed, that is all the way 1 f&cking sided. You've just been bull$hitting about how you're wanted a mixed approach.

Rare $100 charges is trivial to such a large portion of the country that 90% of the public would never bat an eye about running to the emergency room.


You can't educate people to go against their own interests. I mean seriously this isn't rocket science. The smarter a person is the more likely they're to abuse a $100 co-pay not the other way around.

I didn't say that financial penalties were the only way. I legitimately asked to hear your ideas on other ways to encourage responsible behavior with other peoples money. I didn't say "Hey glxpass why don't you tell me about how you are going to decrease it more, pontificate about healthy lifestyles(of which people know and ignore anyway), focus on pre-diagnosis instead of post diagnosis, and then assume you can 'educate' away a person's common sense into picking way cheaper, slightly lower quality healthcare solutions when they aren't paying for it." Because actually the more you educate people on that subject matter the more they're going to realize "Hmm, I'm just one person I wont make a difference on national costs might as well get the most bang for someone else's buck".

Overutilization particularly into quality is the *primary* reason why healthcare costs are so high. Why do you think specialists are making several hundred grand and GP's are making around $100k? It's because everybody wants to see the specialist when someone else is footing the bill.


You still haven't provided a single solution on how to increase patient responsibility for the money they spent on their behalf. Instead you've only offered a suggestion to decrease it drastically with de minimis co pays. And then you pontificate about education when it has zero to do with patients picking quality and quantity after a diagnosis.

So yes I agree that there is the potential for other ways to increase patient responsibility for the spent on their healthcare. Apparently you agree too yet you have have provided zero!!



I'm not trying to pigeonhole you here. That was never my intent and I was genuinely curious to hear what you had to say. The problem is that it's increasingly becoming clear to me that you're pigeonholing yourself by saying you believe in solutions to the issue of patient responsibility and than not providing any! So what am I supposed to do? Should I try to throw out other ideas because you seem to be having problems? Should I just assume that you've been holding back on the things you said you favored an 'integrated approach' to? What? I don't want to be on your case, but for God sakes man write something anything that actually fits with what you say you supported.




P.S. Doctors should play a larger role. But at the end of the day even you have to admit that for a doctor or hospital the thought of trying to save money for an insurance company(as opposed to their patient) isn't that appealing. So does it really surprise you that they aren't that motivated to try to reduce costs by suggesting slightly less beneficial(but substantially cheaper) treatments?

Dshibb, just because you make an assertion doesn't make it true. You've spent much time and energy criticizing what I've said. Simply calling it BS doesn't make it so. Constructive criticism is fine, but you haven't done that. I've provided links, given examples of places using an integrated approach, tried to provide alternative ways of looking at the problem, and so on. You"ve discounted the information I've provided, but replaced it not with facts, but with gross generalizations and opinions.

When you are ready to have a real discussion about these matters, let me know; otherwise I see no point in responding further to your posts.

ETA: An integrated care link: http://www.apa.org/monitor/2009/05/perspectives.aspx

And an excerpt:

So how do we know that integrated care works both for the patient and the health-care system? As early as 1971, data indicated that 50 percent to 80 percent of all medical visits involved patients with no identified physical health problem. Overutilization of medical care by patients with co-occurring physical and psychological complaints has been clearly documented. A meta-analysis of some 91 studies demonstrated a decrease in medical utilization following psychological intervention for 90 percent of those studied.

ETA 2:

Regarding accusing me of BS and your denial of that, you might want to read your prior posts.

You're response is so loaded with bull$hit it's unbelievable.

You've just been bull$hitting about how you're wanted a mixed approach.

I think you need to examine how you express yourself. Frankly, it can be very off putting and deflects from any valid points you might make.



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