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As often happens, we had a spirited conversation in the studio after a show last week. We'd been talking about the signing of the healthcare reform bill with John Evans, an anesthesiologist and the president-elect of the Oregon Medical Association, and Pam Mariea-Nason, the director of health policy and community engagement for CareOregon. John Evans was worried about a provision in the new law that will give a presidentially appointed board the ability to decide what will — and won't — be covered by Medicare. He and Mariea-Nason both spoke approvingly of Oregon's own historic efforts at healthcare prioritization and, more broadly, its culture of cost containment
And they both agreed that — somehow — the cost of healthcare has to be brought under control. But they are not at all sure that the new law will do that.
In short, they gave us the ingredients for another hour of radio.
In this hour we'll talk about the roles of both doctors and patients in containing costs. When do — and when should — doctors think about the cost of care? What about patients?
What conversations about cost, if any, do you have these days when you see your doctor?
What's the right balance between high-cost, high-tech, potentially high-reward medicines or interventions and lower-cost lower-tech, potentially lower-reward ones?
And an overarching question for a society still reverberating from "Death Panel" shouts: is it actually possible to contain healthcare costs in a meaningful way without rationing care?
Tagged as: rx
Photo credit: CarbonNYC / Creative Commons
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I think "rationing" is necessary to containing costs. But I'm not talking about extreme measures, I'm just saying that limits need to be established for what is covered. This only makes sense; if there are no limits, then no matter how much we are willing to spend, it would be possible (and likely) to exceed that, by having a small percentage of very expensive procedures, for instance, or by having a large number of routine over-testing, as another example. With employer provided health care, the actual consumer doesn't think about the costs since they're not directly paying them. So if the physician says brand-name medication is better, they don't ask how much better, and how much more does it cost than generic.
It think it should be possible for some sort of a review board to establish coverage limits that will still give most people more than what they have now, but will keep overall costs lower than they are now.
I think the problem is that this is politically untouchable, and we refuse to talk about it.
Jeremy Hickerson
Salem, Oregon
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I absolutely agree. The Oregonian recently ran an article by a widow questioning whether she and her late husband should have run up $600,000 in insurance payments in his last few years with terminal cancer, with very little clear benefit,in hindsight.
Most Americans with good insurance, like this couple, have a knee-jerk reflex that no efforts should be spared in end-of-life care. I do not think this is equally the culture in the other countries that get better health results while spending half as much overall.
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What are our goals out of national health care? We should expect longer life expectancy, less disability, and lower infant mortality--standard measurable statistics. If we look at the leading of death and disability in America, the top three killers are Heart Disease, Cancer and Strokes.
There is a way to reduce these at almost NO cost. But as usual, it will not occur without kicking and screaming. The leading preventable cause of ALL three top killers is SMOKING. Ban smoking. Or tax it regressively to extinction.
Life expectancy will in short time increase 2-3 years, which is substantial progress in longitudinal population statistics. It would place our nation in the top three of OECD countries. Less smoking in pregnancy, lowers the rates of premature and small infants, and increase infant survival. Smoking bans would lower rates of myocardial infarct and strokes and peripheral vascular disease. It will only improve the health of diabetics, asthmatics and others with chronic lung or heart disease.
This would cost nothing fiscally. And tobacco companies should weigh the loss of revenue to the future litigation costs.
A simple way to improve health of our entire population and SAVE money without spending. Now I anticipate virulent smoker's responses. Be well. :)
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Health-care in America did not get expensive because of the patients. As if the sick were repeatedly running out to Neiman Marcus for yet another 20-ply-cashmere colostomy bag cosy. Of course there is some abuse, but the patients are not at all the problem. The medical industry needs to cut its costs, it needs to stop charging so much for things that shouldn't cost that much. Patients pay more for everything in America, not because everyone is a hypochondriac, but because corporations can get away with it, and have gotten away with it for so long---because there is no single payer system. In other countries the government can provide the services at a lower cost, because they have the buying power of a Wal-mart.
So, no, costs will not get under control, when we are unwilling to have a public option or single-payer system. Americans are so pigheaded that health-care could be the death of their economy. Americans don't have to ration the medical services they receive in any significant way, if they are willing to reform the system, and reform the costs of doing business by acting collectively with the buying power to lower them.
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RE: "Health-care in America did not get expensive because of the patients." While drugs are not the sole source of rising costs, it does present a pressure point in the system that could be used to beat back rising costs and frivolous (unneeded) prescription drug use.
Recall that a decade or two back, federal law was changed to allow easy direct marketing of prescription drugs to consumers i.e. on television commercials. This bypassed the doctor by allowing the pharma industry to pitch directly to consumers: stimulate their fears and little aches and pains. It caused the consumer to go to the doctor's office and demand a particular medication. It would be easy to take that away. Feds should pass a law to recind the right to pitch to the consumer. This should be an easy one-page bill and could take effectimmediately. It would certainly take the fuel away from "the hypochondriac within us," and put the professional, the doctor, back in the driver's seat and allow them to act as the cost-control agent (is this medication really justified?) Putting consumers into the driver's seat for something as complex as prescription drugs was a big mistake.
What is being advertised? The most expensive, patented and proprietary medications: cost the most to produce, but also generate the most profit, and protected by patent for X years. From the corporate POV, these are the medications that one manufacturer has "a lock" on. Pfizer's little blue pill comes to mind, but also the allergy and arthritis medications.
It's a shame that every state has to do their own efficacy studies. What Oregon does at the state makes more sense if it is done for all at the federal level, it would be so much more cost-effective. But the health-industrial complex (yes?) has managed to steer the debate into 50 little subcompartments thus diffusing the effectiveness...
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I simply can't understand how so many people are willing to buy into this notion that it is the public that is responsible. If they are responsible at all, I bet it is like 5% of the problem, and no more. Even progressives seem to buy into this garbage, I think because we all like to blame people, and we especially like to blame Americans for their crappy choices. The industry, pharma, medical and insurance companies created this problem. The public are simply its customers. Since when do we blame the customers of Barney's and Saks for the high prices? It is such nonsense, I can't stand it anymore!!! Are we all this crazed? It is shocking how this whole thing could get spinned into personal responsibility, I am waiting for Dr. Phil to waltz in with his fake smile. I hate the American public, believe me, I would love to blame the customers, but I just don't buy it for a second. If the public is responsible in any way they are simply the product of the system. Who has been lobbying for this lack of reform? The industry! Now the industry is sitting back acting all bashful and meek, while pointing their finger at you and me. Really? No....we are not going to let them hoodwink us again, are we?
P.S. I do realize people will keep taking what they can get, that people are greedy and irresponsible. That we will have to give up some things. But the patient's sacrifices should be the last resort, because they are such a little part of the problem. It is like they expect us to eat at Per Se but telling us we can only order dessert. We need to go to a cheaper restaurant, we don't need to eat less!
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P.S.S. If we start cutting back on visits to the chiropodist, and cutting back on procedures at the gastroenterologists, do you think they are going to lower the prices? Do you think the insurance company is going to lower your premium? Do you think pharma is going to lower the drug prices? Sure we might save our insurance companies money. But what is to stop pharma and the medical industry from raising prices to make up for the lack of revenue from all our cutbacks? Are the shareholders going to be happy? Nope. They are going to find other ways to gouge us.
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We have a 'sickness industry' and NOT a health care system. We have a 'cure for fee' type of medicine being run for the benefit of the medical profession. There is no system anywhere in the resulting hash-up. It is a non system cobbled together to extract the most profit possible for the drug and insurance companies, for the for-profit hospitals and for the doctors.
Sick people are merely the raw material that must be processed in order to obtain the product.. profits. Consider how consistantly the AMA has fought the idea of preventive medicine. The AMA has been shown in actual studies to be concerned only with public health measures when these affects the income of their members. If the affect is negative they always oppose these proposals.
The point is, the goal of a genuine health care system is to maintain the good health of the people. The doctor should be the last person in the system that we should have to see. But our sickness industry thrives only when we are ill. The sicker we are, the more money they make. In a sensible system the medical profession's income should be tied to the good health of the public and NOT to a state of near constant medication and treatment as it is now. Our system is precisely backward in effect for all concerned. It is a shameful, costly mess the American public are kept too ignorant to oppose on principle.
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Dear Gereng,
Preventive medicine is also an overrated panacea cooked up by hippies to save the world and give naturopaths more business. I am all for many aspects, but its impact is going to be marginal in addressing the costs of health-care. It also attempts to blame the public, by saying 'you could have prevented this--if only you had...not eaten gluten, oh yeah, or smoked.' How many diseases can you actually prevent, or prevent with preventative medicine? Even if everyone was already a Goody Two-Shoes the costs of American health-care is still too high. I am a vegetarian, who munches Kashi bars all day, and walks miles every week, if everyone lived like I do, great, but it isn't going to matter that much. This whole thing isn't that complicated, the economic model of American medicine will never work. You can't have an unregulated capitalist system to serve the necessities of life versus death. Because, life is a monopoly, people don't want to die, and the market will be sure to suck every penny from you, if you are wanting to stay alive.
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Scottmil,
I do agree... health care did not get expensive solely because of patients; nor do I buy the notion that it is the public is responsible. We are caught up in a web of profit-seekers...Gereng, jdevine59 -
you seem to be trying to tell us that preventive medicine is the best answer to everything, and I'm not buying it. Though it may reduce the need for expensive services, it will not replace modern medicine (great to augment it though). Do I have to tell you the first-hand stories of people close to me who have (1) bodily injury, (2) cancer by age 50, (3) prostate cancer in 70's, (4) mental illness and/or substance abuse, (5) a cyst the size of a grapefruit, (6) cerebral palsey, (7) already have diabetes. Half these people are a model of health and fitness; some of them were born with it or it was beyond their control, the rest need critical care. I know their personal stories. In most of the cases, no level of measures you describe will resolve their outcome today, and in half these examples the outcome was probably "baked in" either by genetics or circumstance or for reasons that no-one can explain yet.Try telling the guy who worked for the asbestos mine 30 years ago that he should now switch to preventive medicine. Tell me how a fit guy like Lance Armsrong screwed up to get cancer. And if bike seats cause testicular cancer, should we all give up riding bikes? I know two people who swear by alternative medicine who are the sickest persons I know, who may have benefited from some regular checkups and blood tests and instead have developed conditions that are beyond repair.
I have personally heard some real quack medicine in the alternative / preventive community too. I don't buy this thing you seem to be pitching, it is slanted as preventive 100% good, establishment medical as 100% bad. Can you name a fad alternative approach that turned out to be bogus or bunk? If you can't, you are not doing a balanced examination.
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"Recall that a decade or two back, federal law was changed to allow easy direct marketing of prescription drugs to consumers i.e. on television commercials." -- rj oregon
I find this practice annoying, disturbing, and (eventually) disgusting. I don't care for watching tv some evening, and then have to sit through a series of commercials -- oftentimes all in one commercial break for -- Viagra, Lyrica, Levitra, Vytorin, Yaz, Cialis, Lipitor, and Zetia. I really wish that the law were changed back to eliminate direct marketing of prescription meds. Then, maybe, (unfortunately it seems unlikely, however) prescription meds would go down in price since they wouldn't be shelling out hundred$ of thou$and$ of dollar$ for TV ads.
(I really don't want to watch a series of ads for stiffy pills, heart attack preventives, and mood alterers. That plus the crappy all-or-nothing "digital" tv is just about enough to make a girl throw her TV into the street.)
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Obama's healthcare reform is a beginning step in the right direction, far too long delayed. One of the primary reasons that our healthcare is so expensive is because of the huge number of uninsured people; they delay care until the care they require becomes far more extensive and expensive (i.e., emergency room care) than would otherwise have been the case - and those costs are shifted to the rest of us in higher prices for virtually everything, including premiums. Another reason for higher costs is that too many people become sheep to advertising, insisting that their doctors prescribe the latest drug or medical test, even though it may not be the most effective in that circumstance. The public needs to be much better educated about healthcare facts (such as antibiotics not working against viruses, the safety of vaccines), the economic functional underpinnings of healthcare, and the basic functioning of government, in general. We are becoming a nation of illiterate ignoramuses.
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Most Ameicans are both self indulgent and ignorant about health care and how to stay healthy. I lived most of working life in third world countries where disease was rampant and good medical care uncommon. My family and I accepted these risks and managed our own health status. We ate sensibly, took much exercise, no smoking and only very moderate alcohol use (by adults only). As a result both my (then) wife and I are healthy and use no medications of any kind. We are in our mid 70s. She still plays tennis (singles) and I hike and use weights daily.
Our kids are healthy, non- smoking, non-drinking and no drugs...the grandkids follow the same rules and are healthy. The thing I drummed into their head is that THEY are primarily responsible for their own health and NOT some doctor. Who views them only as $$$.
When some flabby, over weight, boozy adult stumbles wheezing into the doctor's office everyone positively DROOLS at the expectation of big profit from the lard arse's condition.
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It all comes down to the fact that there are insurance companies between us and true health care.
Why? Why? Why?
Get rid of all insurance companies and we cut the cost by a third or more.
Seems simple to me.
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I expect insurance companies will gradually get rid of themselves and get out of the business simply because you can't make profit on health care in the long run.
The insurance industry says they're getting only 3% profit. And it should be getting worse as medical costs go up and fewer people have insurance.
I think health care is like fire protection or national defense: we all want it, but it's too expensive for the private sector and it's just unprofittable.
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the new health care reforem (HCF) is not really about reforming the health care system. It is about providing more access, particularly to the working poor, and insurance reform. My biggest concern is putting more people into a broken system that is the leading cause of death in our country. We spend more than double the nearest nation on health care per capita and rank somewhere around 42nd in the world in outcomes. Our health insurance system is like car insurance it pays when you have a wreck. If you want to do health care reform you need to pay for prevention. Spend enough time with the patient to teach them how to take care of themselves and as a last resort use pharmaceuticals and surgery.
Dr. Cynthia Bye
Vancouver WA
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I have worked in the ER for 10+ years. The cost of procedures is never a concern compared to the cost of a lawsuit. 90% of tests are not necessary but are done just to make sure that your covered in case of a lawsuit. If you want to lower healthcare cost first reform malpractice costs.
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Prozacme,
You are absolutely correct!!!!
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One way to lower costs would be to increase the number of doctors by 10-15%. The number of doctors is controlled by the spaces available in mad schools. Those spaces are limited to keep the docotr supply tight and prices up. The tight supply of doctors also leads to difficultuies in seeing a doctor when you need one and serving rural communities.
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I heard only 1 news story explaining why there's a doctor shortage:
they stated that in the 80's, with HMOs coming in to practice preventative care, we wouldn't need as many doctors. So, they reduced the number of openings at medical schools and residency programs.
Apparently, they were wrong.
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The cost problem is a natural result of one group having legal control over an industry. Who else could get away with universal not showing prices?
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Yes. At my last physical, the doctor started checking of tests to do. I asked what these tests cost. She didn't know and said to ask a certain technician. That person got a notebook off a top shelf in a back room to look up the prices.
So now I figure that, on average, each test is $100.
Over the years I've noticed that the same test can vary a lot with time and lab.
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One big reason USA per capita health care expenses are so high is that the middlemen, the insurance companies, take a big slice. However, they do not provide any health care -- they just siphon off the funds. The quality of our health care ranks about 37th in the world, thanks to these unproductive profits.
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Just processing the claims (paperwork), costs well over $300 Billion/yr. (yes, Billion, with a "B").
And marketting costs as much or more.
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Here is how we can reduce costs:
1. Insurance should be billed based in part upon the policy holder's BMI (Basic Metabolic Index). People have to start taking responsibility for the things they CAN control which increase their health risk. Obesity is the single biggest contributor to poor health, and to the high cost of health care at this time.
2. We need to cut all doctor salaries. Doctors in the US make much more than doctors do in any other country relative to the rest of the population and other professionals. In many cases, they are doing a minimum amount of actual care. Actual patient care is done by nurses, medical assistants, and certified nursing assistants. Patients who see a nutritionist often benefit more than if they see a doctor and receive a prescription for statin drugs.
3. We need a lot more mental health treatment and drug & alcohol treatment and a lot LESS prescription drug treatment of every ailment you can imagine. Addiction to prescription drugs is now a huge and costly problem to medical systems. The medical systems are not really addressing the underlying need of many patients. About half of medical care is not addressing the spiritual & emotional hunger that patients have. Spiritual vacuousness and emotional pain are somatized and treated as physical problems--very expensive and ineffective. Massage therapy produces fewer side effects than antidepressants and tranquilizers. So does acupuncture and Chinese medicine.
4. Medical care should be reimbursed based upon effectiveness to the patient, not upon fee for service. European countries are spending about half of what the US spends on care and they have better outcomes as measured by health indicators such as infant mortality, morbidity statistics, etc.
I could go on, but you probably don't have the time in this hour. I work inside the medical system.
Thank you,
Karen Risch
Portland, OR
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As a practicing specialty physician I could make more money in other countries such as Canada or Australia. While true in the not so distant past American physicians were paid more than their counterparts in other first world countries this is no longer the case primiarily secondary to flat physician salaries for the last ten to fifteen years combined with rising living costs and in particular much higher liability insurance costs. Primary care physicians are under paid in this country compared to other nations particularly when factoring in length of training, medical school costs with high debt levels, and liability insurance costs.
Many studies show physican salaries account for no more than 10% of the cost of American medicine. No question there should be more parity in physician salaries across specialities but if Americans want the best and brightest to be their medical doctors a good salary should be provided given the length and cost of medical training combined with the extreme liability issues.
Secondary care providers play an important role but many such as PAs, Nurse Practioners, etc ultimately work under the supervision of a physican who is responsible from a medical-legal standpoint. No question there should be more emphasis in preventive and primary care in this country but keep in mind many medical students do not do primary care residencies because of the relative modest salaries when compared to medical student debt than can easily exceed 300K. No other first world country requires medical students to go into such debt. Are there some outlier physicians who are overpaid? Of course. But I would argue the vast majority of physicians are not overpaid. In debating the hight cost of American medicine compared to other countries look at the one major difference. A multi-payor, private, for profit insurance industry compared to most other countries single payor, not for profit insurance model.
Jonathan Helwig, MD
Portland, OR
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The healthcare 'reform' bill has only added to the burden on the American Middle Class. Lower income and higher income people are already covered. My tax dollars will continue to subsidize medical care for lower income individuals. As someone who makes just a bit too much to qualify for any type of medical subsidy, AND works for a very small employer who can't afford to carry coverage for the less than 10 employees, I can't afford any type of health insurance.
I am offended by our government forcing it's citizens to buy insurance coverage or face a fine. I can afford neither. And quite frankly, I refuse to do both.
I am also offended by the many commentaries and opinion pieces by writers who are certain the problem with our health care system is due to the masses of uninsured. WE are the reason why health care is so expensive for everyone else. Really? A recent commentary in the Oregonian had the writer blaming the uninsured for the high cost and if she could pay her almost $400 a month in premiums, so could everyone else. Must be nice to live in such a fantasy world. I already pay insurance premiums...for our elected officials in Washington.
The reason health care is so expensive is due to GREED of the insurance companies and pharmacutical giants. The reform should have addressed these issues, not hammered an already weary, and dare I say ready for revolt, middle class.
I recently spent 4 hours in the emergency room in Portland. The staggering cost was almost 5000.00, plus meds. My partner spent two nights in a Legacy hospital in Dec 2009..total cost? Almost $12000.00. A doctor visit routinely costs $75 to just walk in the door. My high blood pressure med is $130 a month (it just went up again), yet every strength except the one I use, is now generic. I can change, but this one works for me. Will I be forced to use a cheaper med and risk a stroke? There are definitely time when I can't afford the cost.
Where is the reform for medications? Where is the reform for all of the government tit sucking individuals who misuse the medicare system? Where is the reform for the insurance companies?
Headline in the Oregonion in the last week: Insurance companies, Hospitals and Doctors to see an increase in business and profits...
Ya think?
Yep, sounds like reform to me.
Lynda Elaine
Warren OR
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RE: "I am also offended by the many commentaries and opinion pieces by writers who are certain the problem with our health care system is due to the masses of uninsured."
Please go to Google and type in "cost shifting." I think you are not taking that cost into account.
RE: "Lower income and higher income people are already covered. My tax dollars will continue to subsidize medical care for lower income individuals. As someone who makes just a bit too much to qualify for any type of medical subsidy, AND works for a very small employer who can't afford to carry coverage for the less than 10 employees, I can't afford any type of health insurance."
It seems you refute your own point here while attacking the bill that just passed. To say low and high income people are covered is simply false: we don't ahve health care for all, we have health insurance for "a lot." Look at the number of bankrupcy filings in the US due to excess medical costs among bth insured and uninsured people. Are you saying that the new bill's tax credits, which I believe are on a sliding scale (not just a cut-off) will not provide you relief for the cost of health insurance? That the availability of alternative exchanges will not help your less-than-10 employer find a policy? I agree, however, that I think more must be done to tackle costs, and the bill does not seem to do enough. At least it's a start.
Second, there are unhealthy people who are not covered because they cannot get insurance at any cost (regardless of income), they are rejected from the insurance market. Medicaid and Medicare don't cover a lot of those people (except the most poor). So at least the health bill will provide relief there, eventually.
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Lynda:
The basic idea of health care reform is to make everyone pay so that the whole health care industry is not paid for by just a few.
When you were in the ER, you (and the dozen or so other patients) were paying for that whole ER for that day (cost of the ER divided by the number of paying customers).
One way to keep you from getting stuck with such outrageous charges is to make everyone in Portland (and not just you) pay for the ER.
Since the ER is available to everyone (by law!), everyone should put in a little-- just like police and fire protection.
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Working as a Veterinary Technician, the clinic's policy was to present the client with a detailed estimate before any procedure. If that had been done in my doctor's office, I probably wouldn't have gone through with a simple elective treatment that ended up costing $300. I am so used to insurance covering costs, that I hadn't given the cost a thought.
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Yes - but veterinarians routinely charge more now that at least a percentage of pet guardians have insurance on their pets. Except in emergencies where the vet clinic holds an emotional gun to the pet parent's head saying your pet will die unless you pay us BIG $$$$$ up front but of course we don't guarantee your pet will live but you still have to pay us BIG $$$$ up front as in RIGHT NOW or we'll letyour pet die right here or you can take your pet home to die.
Having had dogs and horses for the better part of my sixty years and seeing the veterinary profession disintegrate into the obscene money-grubbing/don't care about the patient but only the money/get the money first regardless of the situation that exists in human medicine, I don't hold out any hope that any medical provider for human OR animal has any ethics left whatsoever. It's all about the money - those of us with half a brain figured that out about 15 years ago when the almighty dollar became the sole and only reason for people to take up the practice of any kind of medicine. I actually had a vet say to me and repeat happily several times when discussing a medical procedure needed for a horse - not emergency but nonetheless very much needed - "all you need to do is decide how much money you want to spend." Until I gave them a dollar figure of what I "wanted to spend", while still not knowing their usual and customary charges for the procedure, they would not give me any answers whatsoever to the cost inquiry. When they did, it was about 10% more than I had hazarded a guess on.
And you can't shop these things because the vets all talk to each other and I have ACTUALLY HEARD a vet tech make calls to several other veterinarians' offices and say "so and so is shopping around" and then the veterinarian at the original clinic calls the pet parent who is desperately seeking affordable medical care for their pet and abusively screams at them for doing so. Personal experience.
Vets are just as bad as doctors. It is ALL and ONLY about the money.
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If society as a whole followed a whole foods Mediterranean diet with regular exercise and cessation of smoking, healthcare costs could be lowered by at least 50% with no cost to the government or to consumers. Joe Emerson, Portland
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Until a few decades ago, drugs were advertised in the professional magazines for doctors, but they were not advertised to the public. The change has created high demand for the newest and highest-priced drugs, and has therefore increased costs substantially without significant improvement in health results compared to what we would have with advertising only to doctors.
We should reverse this change by giving Medicare and other government drug purchases default (not be limited to, but just a default preference) for drugs from companies that do not advertise to the public.
Daniel M
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Drug companies spend around $350 Billion each year just for marketting.
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I recently received a bill from a Gastroenterologist for $411.00. His bill was actually $540 but my insurance allowed $411. This was a routine visit....10 min. When I called my insurance company to inquire as to why they would allow such an outrageous amount they said other wise, the Physician wouldn't accept their insurance. The large fees that Physician's are asking is one of the reasons insurance premiums are so very high. When I called the business office to ask for a review of the coding, I asked why they do not tell the patient the approximate cost of the visit so one could shop around. They explained that they would not know the cost until after the visit. Since I have a very large deductible, this was all out of pocket. Another example of unorganization.
Elizabeth Huntzinger, Portland
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Tort reform is a key element of lowering medical costs.
I say this a lifeling Democrat and spouse of a doctor. My MD wife regularly orders additional tests, visits to specialists and such follow ups for her patients, not because it will result in better patient care, but, sadly, due ONLY to her fear of being sued.
For example, someone might have a 1% chance of a freckle being skin cancer. Does the doctor explain this to the patient and send them on their way? No.
The doctor will typically order a biopsy anyway for ALL patients she sees with the freckle. If she does not do so, and a patient later gets skin cancer, she may be sued for "missing" it. This means that 99 people will get a biopsy / uneeded treatment simpy because a MD is afraid of getting sued by one person.
This practice of Cover Your A** (CYA) medicine adds greatly to medical costs. Tort reform for medical malpractice cases will result in lower rmedical costs for us all.
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As follow up to the coment that patients will "go across the street and get the pill they do not need". Often "across the street" is the Emergency Room. The most expensive option for routine care. As more and more patients choose to use the ER as primary care cost skyrocket. Patients will shop around until they find a doctor that gives them what they want, not what they need.
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Up to 25% of all health care costs go for patients in the last year of their life. I expect that most of these expenses are publicly funded, which means physicians, care centers, and patients have no real sense of how much any of this care costs. Indeed, they have no incentive for knowing the amount of money that is spent on new hips, more pills, care, etc.
We do not need death panels. We may not even need rationing. We do need people to understand how much everyone pays for extaordinarily expensive care.
My doctor recently prescribed an MRI for a sore shoulder, even after an x-ray gave a very clear indication of the problem. The MRI was to "just be sure." I subsequently learned that my costs for the MRI would be close to $600, while my insurance would have to kick in $2300. I thought the latter figure was obscene. Why should ohers pay so much for something that really wasn't necessary. After all, it was just a sore shoulder. My doctor had no idea of the costs, and when I told him he started to have second thoughts about glibly prescribing such matters.
I don't want to ramble, but in this case I believe some clear discussions about costs is needed. It is ignored for various reasons, but such ignorance directly feeds high costs and high (unearned) profits.
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"Just to be sure" is doctorspeak.
It really means "So you won't try to sue me later if it turns out to something different."
Here's an idea: Rather then ordering the MRI, the doctor asks the patient to simply sign a waiver/dicclaimer saying "I, the patient, choose not to get the MRI, and promise never to sue this doctor regarding my sore shoulder."
PROS: The patient gets a good outcome, and avoids $600 in out of pocket costs. The doctor is relieved because he/she knows they will never get sued. Everyone else sees one less unneeded expensive procedure, thus incrementally lowering insurance costs for everyone.
CONS: none that I can see.
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The cost of the MRI is an eye opener. Isn't it also the case that there are stand-alone for-profit MRI centers that would charge you one tenth the cost for the same procedure? I also read that manufacturers in Asia came to market with newer cheaper machines to address the high cost of first-generation devices. I suspect these new small MRIs are the ones installed in trailers and shopping malls by the stand-alone services.
Are we paying 9/10ths just to have our doctor check over the result? Well, I doubt it really (don't blame your physician, who probably doesn't know the billing). The hospital board / administrator goes out buys the machine, expects to pay for it in N years. Once the cost is recovered and maintenance is paid for, it's a cash cow for the hospital, and the profit is used to spread out on other areas that lose money (there's the cost shifting) or to fatten the bottom line or to save money for the next hospital wing construction fund.
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A couple of points:
First:
Some 35 to 40% of biomedical research is underwritten by the federal government, and anoth 10 to 15% comes from charitable organizations, so the idea that insurers (single payer or otherwise) need to cover potentially useless or dangerous devices/drugs to ensure inovation is dubious.
Second:
An insurer (government single payer or private) not covering a particular procedure when it is availble for cash paying patients or patients with suplemental plans is not the same thing as rationing. If it were then healthcare has always been rationed. The use of the term "rationing" is a scare tactic used by critics of much need health care reform.
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I would like to hear your guests comment on the "medical home" model, also called the "patient-centered primary care home" model . We know that a system like this that emphasizes primary care, coordination of care, preventive care and optimal management of chronic illness leads to better clinical outcomes at a lower cost than our current fragmented system.
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I've never heard of this, saw an AAFP document here. At first glance it seems that coordination of care across all the care providers is the key component.
I wonder,
doesn't an HMO plan like Kaiser try to do the same thing (all services under one roof)? How does it differ?
Does the current VA system constitute a medical home provider? (Aside from the fact that pediatrics is not part of the base population, it's mature adults.) I mean look at it, there even are VA homes for elder care (my uncle was in one until the end of his life.) -
Medical Home model is being touted as one solution, and I believe this would help solve many of the problems discussed today. However, ir is not yet a payable service so it won't happen until the payers (patients, private insurance, Medicare, Medicaid, etc.) decide it is worth paying for.
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I am frustrated with the comments of patients asking for perscriptions even when they dont need them. It seems that doctors are just as guilty. My Grandmother was perscribed medication from her doctor, which would cost her anywhere from $10 to $200 in co-pays only to have the doctor decide a week later that that medication was not what was needed and would perscribe something else. After her death she had BOXES of medication that she had only used for a week or two and was told not to take any longer. This cost medicare and seniors a huge amount of money that they can not afford. I am now seeing the same trend in my parents medications.
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Have you tried asking how much a treatment will cost before having it?? Next to impossible to find out many times, and costs seem to vary depending on which insurance or whether one has it or not.
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Lifestyle choices and p-e-r-s-o-n-a-l r-e-s-p-o-n-s-i b-i-l-i-t-y. Why don't people get it? We are a sick nation, and we have a sick care system that is out of control. As long as people do what they want to do, and hope for a quick fix with drugs, surgery or whatever the medical field can come up with, and as long as THEY put so much emphasis on studies, screening, testing and "finding a cure" instead of focusing on what caused the problem in the first place, well, all this is an opportunity for doctors, hospitals, drug companies, pharmacies, nursing homes, etc. to make a buck. And why not? Think of all the JOBS it provides!
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Personal responsibility, maybe 50%, but by pegging it on "lifestyle choices" you seem to say all health outcomes can be influenced by choice. Oh, I choose not to be poor? By personal responsibility I might work my way out of that circumstance... in the better part of a lifetime. I choose not to have birth defects? I "choose" to never have a auto/pedestrian accident or any injuries, like breaking a leg skiing. There. Mind and will over matter.
Doesn't work for me in the real world.
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I completely agree that one problem is the expectation that our medical system can diagnose and fix every ill. Death, while inevitable, is viewed as an essential failure of the system. We are saved from our first, second, and sometimes third natural death, leading to an ever increasing population of frail elderly who are highly dependent and have costly chronic health care needs.
My mother-in-law recently died at the age of 88. The hospital bill alone for the last 8 hours of her life was about $20,000. That would have paid for a LOT of preventative care! While I dearly loved her, the extreme cost of trying to prevent her death seems incredibly unethical. (Incidentally, she did have advance directives that as for no heroic measures - just comfort care. That was ignored by the hospital in the intensity of trying to keep her alive.)
Until we, as a society, stop expecting medicine to beat death, we will continue to have costs spiraling out of control.
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Excellent points. I feel for you and your grandmother, in part because it is such a common experience. What is less widespread, but I believe very necessary, are some clear expressions about the morality of refusing so much life extending care. When the time comes, I am quite certain that I will refuse certain treatments on what I deem socially moral grounds. My desire is that such a decision will be viewed as responsible, and not slotted away with faith healers or some other disregarded or denigrated group.
We need to be clear that death is not "failure" --as you say--and that "extending life" is not unalloyed success. Instead of "wanting the best" for grandma, my child, my spouse --"no matter the cost" --the moral decision needs to be based on what is best for the community. Selfish, personal healthcare actions are too often construed as moral absolutes. Community-based decisions, which might raise questions about sustaining the heart functions of alzheimer's patient or ensuring the live-birth of a 22 week old fetus, need to be accorded similar moral heft.
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I know there is always a gap between "programs" and
"implementatin", however, why is there not more emphasis on preventative care, including dental care, support for quiting smoking, improving diet and exercise as the foundation for a national care model regardless of who pays?Additionally, prices for all procedures need to be transparent, it is well nigh impossible to do any comparision "shopping" in the system as it now exists. As well, as easier ways for us to become more informed consumers. I recently have found this difficult - as an uninsured 61 year old have tried to get prices for procedures in order to plan care. One clinic wanted to charge me a $200 deposit and at least $100 at each visit there after, even if I paid in full with credit card and didn't have a list of fees.
I believe most of us want to be more informed consumers and find th at process difficult. (I have medical care and billing background and still find it hard.)
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Why is Adrienne's thalomid therapy being billed to insurance? Shouldn't the pharm corporation that will ultimately profit from the marketing of the drug pay for her drug? Many drugs are developed with public dollars, then turned over to industry. Perhaps we should require industry to pay back the costs of the early studies that they are benefiting from.
- Teresa RN,PhD
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The two physicians were talking about the disorganization in the ordinary practice of medicine. The highly organized program of experimental research doesn't have any bearing on that, except that it illustrates the usefulness of computers for coordination of everyday medical services.
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The current health care reform bill (HR3590) mostly has focused on reforming health care insurance. Another area which might need as much reform is the provider system itself.
Here are some interesting facts on the provider medical market and influence:
The US has one of the lowest number of MD's per capita in the industrialized world.
According to CNN Money the top 4 paying jobs in the US are all medical professionals. According to the Bureau of Labor and Statistics, 8 of the top ten jobs (average hourly wage) are MDs.
Only 3,500 US trained MDs compared with 7,000 international peers will enter graduate training (medical residencies) in US medical hospitals according to the Center for Workplace Studies.
During the 1980's and 1990's only one US medical has been established.
According to Open Secrets, the American Medical Association (AMA), and American Hospital Association (AHA) ranked number 2 and 5 respectively in spending as lobby client groups in the US (1998-2009).
According to OHSU (web site) they receive 4,578 applicants and graduate 120 MDs (2.6 % applicant to graduate rate). They accept about 4.8%.
Based on much of my understanding of the marketplace, there is an intentional undersupply of medical providers for decades, with the help of powerful lobbyists in our government. For example, if we have fully functioning provider marketplace, why would a president need to have special meetings with the AMA and AHA?
I have personal evidence of my suspicions. I recently noticed that my medical provider charged $1,100 (2 patients) for a junior high school checkup (with immunizations). Since we thought the provider was expensive, we asked if we could see a list of the prices for services. The provider refused to provide any list of prices, and told us that we needed to ask for a particular service in order to get a price. So imagine going into a store, or a repair shop where prices are not known.
Here are some more questions for us to think about:
How often do you ask how much a service costs?
Are prices for medical services easy to find (like all the other services we use)?
How often do you shop for medical services?
How often do you review the billed amount for a service?
Thanks for letting me think and speak out loud.
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Hey George,
Listening to you on OPB. I have Multiple Myeloma but the good news is that after a stem cell transplant and chemo I am still looking down at the grass. Thought I'd let you know Kim's married and has her first child due in June. Rafe still flying for the Navy and has two sons. Lark with Citizens Bank in Corvallis and will retire next year. Hope all is well with you and yours.
Bill
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Bill, So nice to hear from and about a former family of patients of mine, and that you and Lark and your two wonderful kids are all doing so well. Give my best to all four of you who (my former Madras patients and friends). Give me a call if you are ever in Portland and we can catch up on old times.
George
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Not enough conversation about care issues occurs in general with the public and not just with our parents. We all have to make health care decisions in a fair and reasonable way that takes in to consideration everyone else on the planet. Cost increases can simply be reduced by reducing profits and wages across the board for everyone.
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Please ask your guests if they would ban the use of direct-to-consumer advertising, especially in television as a measure to control US drug costs and patient expectations.
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Most doctors would love it if direct to consumer drug advertising could be banned, but the Supreme Court has ruled that this is free speech and, therefore, legal.
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Hi my name is Marie and i"m diabetic. Aside from taking my diabetic pills, am also taking Lipitor for chollesterol. My question is why Lipitor and Crestor (generic) always change their prices. Pharmacist said when Lipitor is lower Crestor is higher and vice versa all the time. I'm concerned about the effect on me from those 2 medicines because I requested my doctor to change it whichever is cheaper. Now Lipitor is $65.00 for only 30 pcs.
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I'm listening on the radio and I'm wondering why doctors more and more prescribe drugs before diagnosing the problem. Is this to save the cost of diagnosis, or is it because the doctor is trying to rush to his next patient?
I have several personal experiences and others I've heard from family and friends where the patient had to actually steadfastedly refuse treatment until a diagnosis had been performed. In one case of mine, the doctor was very put out with me and she said 'I'll do the diagnosis if you insist, but I'm almost positive I know what the problem is.' or words to that effect. After the diagnosis was done, it turned out that she was wrong. When I asked her what would have happened if I'd just taken the pills without a diagnosis, she kept saying it wouldn't have hurt me, and it was like pulling teeth to get her to admit that it would have been a waste of money for me to have filled the perscription. In another case (my mom's) she was prescribed antibiotics when the doctor was only guessing that the problem was a bacterial infection (tests eventually proved otherwise).
I hear doctors complaining on air that patients are "demanding treatment". Well here's a patient that finds that he has to stubborningly demand diagnosis and refuse treatment until diagnosis is done. Why is this?
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Johnreid:
Fee for treatment, versus a flat salary. Is it any wonder that every visit seems to result in a "procedure" or a prescription? Didn't I hear the panelist say the VA doctor works on flat salary? Isn't that better?
Just as a counterpoint: with advancing age I get more regular checkups, and with a change of insurance I found a new physician. I told him I don't take any medications period (except multivitamin) and his response was: "good." I tell you that exchange was rewarding. To his credit, he was pleased to go with the "less is more" approach and is interested in preventive care. If you can, shop for a physician who agrees with your view.
Keep in mind, all physicians and hospitals are lobbied heavily by pharma/equipment sales reps, right up to and including kickbacks and bribes and "incentive programs" (which in theory have been "banned"). Pharma and equipment companies are conducting a "war for market share" every day. This is our free market capitalism-in-healthcare operating in its normal mode. The doctor receives pressure in this. The consumer is bombarded by ads catering to their fears (or their libedo, or vanity), selling drugs, selling "food porn" (ever wonder why we eat so many calories?), and so on.
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Incentivize the off-shoring on non-emergency medical care, procedures and surgeries as well as prescription drugs.
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I don't want to direct this in particular to josephemer (posting today), but to the broader group of posters on this and several of the health forums. They make statements like, with the right diet "healthcare costs could be lowered by at least 50% with no cost to the government or to consumers."
To you folks who only say diet is the be-all and end-all:
Will the right diet help a schizophrenic or a manic depressive stay on their meds? And will a good diet pay for those meds and the weekly visits to the shrink? Their life literally depends on it.
What role can diet play for someone with cerebral palsey, or... pick your affliction.
Diet can contribute to dental health, but you still need to perform dental "maintaenance" for good health.
Are Mediterranians free from all disease and cancer? I know, the studies say there is reduced incidence... It is not treatment.
Can a person who overeats, or has metabolic problems that turn anything they eat into stored fat, reliably solve this problem through diet? Obesity cetainly is a problem here, but "good foods" have calories too.
About cost: Let me ask you another question: where do you buy your food, and how much time and $ do you dedicate to preparing (and shopping for) food? So, are you privileged to live in... a natural-foods neighborhood. Face it, I shop some of these places because I can, and what I spend is above average and over what many can afford.
When will good wholesome foods be available cheap and widespread in all neighborhods, maybe the neighborhoods you've never been to, maybe the rural area where there is no grocery store or the grocery section has a choice of three "fresh vegetables" (potatoes, onions, and square tomatos), and, available to those folks who get off work after 10PM...
Diet is (generally) not paliative care. Diet does not prevent accidents. And it does not drive disease to 0%, so you still need health care and a system to deliver care. You still need some care at end-of-life.
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Next step: don't allow the drug or insurance industry to hide behind exemptions from anti-trust law in the U.S. Petition your representatives to enact legislatation this year. That's how you control costs: don't allow these industries to operate as a monopoly!
As reported in the NY Times here (March 18 2010, mis-titled as "In New Health Care Package, Drug Makers to Pay More"), the reconciliation bill gets the drug industry to pay out $28 billion. In the Senate package, it was to be $23 billion, reconciliation bumped that up to $28 billion. ("The pharmaceutical industry fee is graduated, with $2.5 billion to be paid in 2011, $3 billion from 2012 to 2016, $3.5 billion in 2017, $4.2 billion in 2018, and $2.8 billion in 2019 and thereafter.")
But, that concession is nothing compared to what was to be under the original House bill that didn't get enacted. As reported in the Washington Insider here (March 18 2010, "How reconciliation Irons Out the House and Senate Health Bills"):
"The nation’s drug makers, under that agreement, would dedicate $80 billion toward health care reform over the next decade if Democrats would oppose further industry reforms..." like
"... allowing Americans to buy their prescriptions from abroad, and .... empowering states to negotiate directly with companies on behalf of their lowest-income seniors."
Rep Waxman managed to keep the provision allowing state negotiations for low-income seniors, but lost the other provisions. In the end, the bite out of pharma's hide went from $80 billion down to $28 billion.Again, the NYT article,
"... drug makers plan to support the new bill. Americans for Stable and Quality Health Care, a group largely funded by the pharmaceutical industry, has unveiled a..."
30-second TV spot endorsing the house vote on the Senate bill. If they were for it, I suspect they think they cut a sweet deal. -
Dang I JUST LOVE it when the media and those chosen to be interviewed for the media (usually the rich folks and the doctors) engage in a bottomless game of victim blaming - that is, blame the high cost of health care on the patients who, it is strongly implied, are either a) hypochondriacs, b) DEMANDING expensive procedures just because someone else is paying for it if they have insurance, c) sue-em-all types just waiting to lawyer up if a doctor doesn't give 'em what they are DEMANDING, or d) all of the above. No one, it seems, if that is a doctor or pharmacy company, is willing to look at what they themselves are doing to hike up health care costs.
I'll give you TRUE rationing: it is called "NO health care" for people who are currently uninsured because they can't afford the insurance or uninsured doctor visits, and it will continue to be called "NO health care" for those who continue even in 2014 to be unable to afford the mandated purchases - they will be too overburdened with stiff financial penalties (that the IRS has vowed to enforce, a gestapo-like tactic if ever I heard of one), to pay for even the most minor doctor visit.
There are an awful lot of folks out there - I have talked to some here in Eugene in recent weeks - who think that people really are choosing to die and in fact SHOULD die rather than one single penny of those local folks' money go to any kind of a Medicare for all program or universal care or single payer or even a public option. Look around you: the people who developed ObamaCare HAVE access to health care because they HAVE money or control a great deal of it (the health insurance companies having heavily contributed to both parties and having participated in development of the legislation).
The reality is this: the only real health care is for those with money. The reality after watching this for the past year and a half? For those not monied, rationing-to-zero health care is what happens.
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In America, the land of Guns and Morals,
You can bring a gun to Starbucks, but the Barrista cannot serve a dollop of Kahlua or Bailey's Irish Cream to a Latte like in Paris.
Only Leaded Lattes, Not Alcoholic ones.
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Comments are now closed.
ALL 'care' systems ration one way or other [1st misnomer/euphemism -- we have sick care, not care that really promotes health]. Here, we ration by $ -- either your own, or 'insurance' [another misnomer/euphemism - not like auto, home, or other insurance to cover more extreme risks -- but funding scheme to pay for nearly everything everyday]. In others, they do it thru 'advice' on appropriate treatment ("NICE" in the UK), or long waitlists (Canada).
The question is HOW we ration 'health care,' not whether we will. We don't need 'Death Panels' (altho' that might not be a bad idea -- some societies have grandparents wander off into winter when times are tough), altho evidence-based comparative effectiveness results should guide us -- much $ is wasted on ineffective procedures, especially on elderly in the last months of life.
Rational approach already tried here in Oregon - priorities ranked by effectiveness and cost (bang for buck). Those at top get $, and at some point the budget runs out and those further down list don't get public funding.
Important! This does not mean no other 'treatments' are offered, just that public/taxpayer doesn't pay for it. One can pay on one's own, or have 'insurance', or in more extreme cases folks do charity drives. ['Treatment' is used loosely here - science shows most of what passes for 'treatment' is not supported by rigorous study, and in fact, many 'treatments' pose the risk of more harm than good - see, e.g., iatrogenic illness.]
Higher costs come because we have an 'insurance' system to fund it. Basic economics of 'price illusion' (seems 'free' because little or no payment @ time/point of service, even tho quite expensive because you've prepaid via premiums or taxes), and 'moral hazard' (folks take on more risk because they now have the 'risk pool'/other people taking up financial risk). Collectively & historically we have made it much more expensive by having "someone else" pay for these services. That said, we have legacy system and most are loath to change (they prefer the devil they know rather than unknown). Given that, there are many ways to reduce costs -- standardize & streamline paperwork, etc. Other Western systems do this to varying degrees by centralization of one sort or another. Unfortunately, current legislation doesn't really do this.