the healthcare debate continued
This is a reply to a reply to one of my posts called healthcare for all.. if that's not too confusing read on.
Thanks for reading and writing. I was wondering if anyone was actually reading this but apparently you are. I love how you muddy the water because it keeps me sharp. I don’t remember if I posted my review of why medicine is basically a weird combination of socialism and capitalism where everyone gets what they need to not die and then overpays for it. If not I’ll post it later if so… well… then I posted it.
Anyway last things first. Pages 56, 57 and 58 (pages 68-69-70 on the PDF. I will continue to put PDF. References in parenthesis) are examples of higher satisfaction rates exhibited by Medicare patients vs. Medicaid patients vs. Private insurance. I will say that yes they do indicate that Doctors are satisfying more slightly more Medicare patients than the other covered patients. What I believe is happening here is simply related to expectation. The elderly are comfortable with waiting a long period of time for a short interaction; privately insured patients are generally younger and have a different expectation of value and Medicaid patients have a sense of entitlement since they are already on the receiving end from the Government.
The data seems to agree with that assessment and although you can’t cookie cutter it that easily I think that it may explain some variety. Page 56 appears to me to be about 52%, 54% and 58%. This is not an amazing difference and in reality that number alone is shameful. So you basically flip a coin and that determines if you’ll get timely care. It’s absolutely true but still terrible. I think the chart on page 57 should have displayed in the opposite direction but that’s not my prerogative. The chart says similar things although the Medicaid component is flipped probably giving a bit less credibility to my previous hypothesis. Still 58% to about 68% in the grand scheme of satisfaction doesn’t appear to indicate a particularly strong job being done. The chart on page 58 (70) to me is significant. The Medicare patients indicate that they get better care probably about 20% more than the private insurance. However the real question here is do they get the care they seem to indicate? Obviously they are very wrong in their assessment of the system. Page 48 (60) indicates that the care received by the elderly, who are very often Medicare patients is terrible. I’ll excerpt the bullet points here.
The percentage of quality standards met varies for different types of care■ Standards were met least often for preventive care—43 percent of the time. Standards met for diagnosis were only slightly higher at 46 percent■ Standards were met most often for treatment (80 percent)■ This difference might be explained by the nature of the U.S. health care system, which reimburses providers for time spent performing procedures and prescribing medications, but not for time spent taking thorough histories or providing preventive counseling■ Researchers also found that providers administered proper care to patients with conditions that needed immediate treatment (acute conditions) far more frequently than to those with chronic health problems—83 percent of the time versus 51 percent
In summary the care being provided to the elderly sucks. There is no way to sugar coat that. The government (Medicare) pays the providers for doing not caring. Almost all insurers follow a standard which is known as Local Medicare Review Policy or LMRP. This basically compares the International Statistical Classification of Diseases and Related Health Problems commonly known as ICD-9 (diagnosis in number format) with the Current Procedural Terminology which is most commonly known as CPT and is a number which corresponds to a test or procedure that you order or perform. So in reality the private insurance might pay slightly more than Medicare but they basically pay for the same things. Since doctors are still based mostly on paper they have to have a coder to determine what is covered for what or know it on their own. Commonly this results in a claim denied letter because your doctor chose the wrong ICD-9 for your test. So I don’t believe in anyway shape or form is the care provided to Medicare/Medicaid particularly superior to that provided by private insurance. In a nutshell the reason private insurance companies pay doctors slightly more than Medicare/Medicaid is they can’t force you to take on their patients (unlike the government) and if they don’t have doctors taking their payments they have no one to send their clients to and the clients don’t renew resulting in lost revenues etc…
Page 41 (53) is significantly more disturbing than even the previous information.
RAND’s national study found deficits in quality of care across all types of care—chronic, preventive, and acute■ Recommended care for managing chronic conditions (e.g., diabetes and hypertension) was provided 56 percent of the time■ Preventive care (e.g., flu shots, mammograms and smoking cessation counseling) met quality standards 55 percent of the time■ Recommended care for acute health problems (e.g., pneumonia and urinary tract infections) was provided 54 percent of the time
These are well established issues that are simply not getting done with any greater regularity than a coin flip. Seriously people are not getting flu shots, mammograms and being told to stop smoking? The answer to that is yes and it’s painfully obvious.
The system is somewhat business run but in the end it is still government run. The government keeps up significant barriers to entry which fails to allow competition and serve to keep prices artificially high. I know it appears to be privately run but care standards are established by someone other than the doctor, payment levels are set by someone other than the doctor and setting up a practice requires extensive government involvement.
The rand report indicates the exceptional and widespread failures of the system but I would agree that seeking treatment less often is not an adverse health effect. Of course not going to the doctor is an adverse health effect especially when you have an undiagnosed illness that gets worse. My solution is not to increase co-pays which is simply increasing the hassle factor and attempting to discourage use but to continue to introduce real free markets.
I love concierge medicine and think it is an excellent solution to some of the ills now plaguing the system. (Disclaimer my Doctor is a Concierge Physician) Before anyone jumps in with the worn out argument that this is discriminatory against the poor… yes it is absolutely and without apology. The current system is rationed by time with means it is costly enough the solution is to ration care by money. This is the real solution because it means that the tide can change. There are less and less people becoming doctors and why is that you ask. Well because working like a dog 7 days a week for only 120K after all that schooling is a waste when they can go to Wall St. and do that for an investment bank and get paid much better. How do we get more doctors up the pay and decrease the hassle factor leading them to actually provide care for their patients rather than herding them like cattle. If you don’t like things being rationed by money then there is a nice island nation where that’s not happening… hint you can take a short boat ride there. Here’s something else rationed by money Porsches. I want one but I can’t afford it (yet). So I have a Toyota Yaris which I love and is awesome on gas. The really poor don’t have a Yaris and especially not a Porsche but do we really care about that? Porsches and S-Classes are elitist but don’t we all want them. Possibly included in that is the Venti Soy Vanilla Latte I love so much. Simple economics indicates that money talks.
Oh and here’s something that is not in the Rand report… my doctor would score 100% on all the care standards because he’s not overworked and actually has time to care for his patients. Can I get timely care… sure I call his cell phone and he’ll make a house call if necessary. Sure there is some cost sharing, I pay him. However the reward is that I go pretty much every month just to check in and see how I’m feeling, I never wait in a waiting room, and my appointments are never less than an hour. You’re probably saying how can I get that? I’m saying you probably can’t because the socialists in the system want to keep you from getting good care. It’s like saying because the poor can’t afford Porsches no one should have them. The poor get bad medical care so you should too. I say absolutely not to that. Before my current physician I didn’t really go to the doctor because I’m not cattle and I will not be herded into a waiting room full of people coughing on me and sit there for an hour when I made an appointment. I will not be seen for 5-10 minutes poked/prodded and given 1 minute to voice any concerns. I have seen the light on the other side and understand the value of a dollar. This is an example of where private business hammers the government left, right and center.
Steven I appreciate your comments because they are always so challenging and keep me thinking. Like always we are in the same pond probably near the middle just on slightly different sand bars.