Part 4 - The Safety Net
(This is the final part of the series. I'll return to lighter topics soon enough.)
So what do we do about the struggling families who can't afford insurance, who don't want to pay for insurance, or who have chronic illnesses that effectively disqualify them from insurance plans? We definitely need a safety net for these folks. If we as a society are willing to pay for the care of the totally disabled, then we should be willing to support the working class when they need a little bit of help too. But as the brilliant Bill Whittle once wrote,
"I’m all for a safety net. It’s the safety hammock I have a problem with."
I think it's important to try to keep health insurance affordable via sensible but not overbearing insurance reforms, so that the healthier segment of the "struggling family" group can purchase private insurance if they choose to pay for a higher tier of healthcare. The sicker or lower-income members of this group should probably be covered by state or federal assistance programs instead. These folks don't need "insurance" anyway...they need someone else to pay their medical bills for them. They are the ones who need government handouts, not the rest of us, so I am against any plan that would force healthcare rationing on the population at large. And to answer a previous question by Ms. Alison Cummins, this same safety net (and the lower tier of care it represents) applies to the previously healthy/insured patient who because of financial or medical disaster finds himself unable to afford the higher tier of medical care he previously enjoyed.
Providing the care
Why not increase indigent medical access by increasing the role (and perhaps the number) of our outstanding medical training programs? We can expand the services provided by medical students and residents at the state and county level, using a sliding scale for charges based upon income. In my experience, indigent patients are typically appreciative of the relatively inexpensive and compassionate care provided by medical trainees. Insured patients, on the other hand, occasionally disdain such treatment. Despite the perception of a lower tier, the quality of care that is provided by housestaff and supervised by teaching physicians is often superior to that offered in private facilities. It surely isn't as convenient, but convenience is something you pay extra for.
I suggest that community indigent clinics could also be staffed on a rotating basis by physicians who have been disciplined by their state medical boards as a retribution for various medical misbehaviors. Volunteer physicians might also staff such clinics if they were offered some sort of tax writeoff and malpractice protection.
The additional cost to patients
Access to discounted rates for medical services do not come without a cost to the relatively indigent but able-bodied individuals. They should have to make some sacrifices in order to obtain their bargain medical care. They will have to pay their dues by allowing themselves to be on the teaching service, to obtain primary care by less-experienced (but supervised) physicians, and to accept thepossibility likelihood of increased waiting times, fewer clinic locations, and decreased availability of expensive therapies. They may be able to obtain certain more expensive services or medications by participating in research studies coordinated by the teaching hospitals.
Funding for these programs should be primarily the responsibility of the individual states
I suggest that each state should be primarily responsible for funding their own indigent and preventive medicine programs as they see fit, perhaps with some limited federal assistance or incentives. In Texas we fund our programs with sales taxes and property taxes, and we still don't have a state income tax. Teaching hospitals should establish or expand programs which send medical students and residents to satellite facilities in their state for clinical rotations. That would provide better access of care to uninsured patients, enhance the educational experience of budding physicians, and perhaps increase student interest in primary care. Expanding the concept of student loan deferment for physicians who agree to practice in these rural communities for a given period of time might be a good idea too.
EMTALA - follow the original intent
Acceptance of transfers of stabilized indigent patients who present to community hospitals should be expedited by state/county facilities so that definitive care can be provided by the funded teaching hospitals. If EMTALA is going to remain the law of the land, then the original concept should be followed rather than the tar baby into which it has evolved.
Tort reform can increase access and reduce costs
(edited for clarity)
One of the biggest crises in America today is the increasing difficulty of obtaining emergency surgical specialty care. Neurosurgeons, Orthopedists, Ophthalmologists, and Plastic Surgeons, for example, are avoiding ER call by giving up their hospital privileges to practice in free-standing surgical centers, leaving trauma patients in some areas with limited access to critically important services.
Optimally, the provision of free medical care (edit: such as that provided under EMTALA) should operate under the protection of Good Samaritan laws, thereby eliminating the prospect of malpractice torts and the extra associated costs of defensive medicine. If a patient is receiving free medical care, why in the heck should he be allowed to sue for a bad outcome? I think more (specialist) physicians would be willing to provide unreimbursed (emergency) treatment if they were immune from lawsuits. Alternatively, incentives to provide uncompensated medical care could be given to physicians by allowing them to write off the costs of their unpaid services as charitable donations.
"Self pay" patients should also be able to barter for discounted emergency or nonemergency care if they agree to sign a waiver releasing the treating physician from malpractice liability, or perhaps limiting the scope of such liability. With the current system, the patient is forced to pay for maximum liability protection for each and every encounter. High risk patients, therefore, often find it difficult to obtain medical treatment. Allowing more flexibility in this area is another potential way to reduce cost and increase access to medical services.
The trauma fund
Finally, a catastrophic medical fund should be established to help pay for uncompensated trauma care. And I would suggest that this money should be distributed by each state wherever it is needed most, such as a rural EMS system, an inner city trauma center, a LifeFlight program, or even to build additional county medical facilities. This could be partially funded by additional levies on automobile sales, drivers licensing, automobile registration, gasoline, traffic violations or various misdemeanors and felonies. Other options include specific taxes on the sales of motorcycles, skateboards, or rock-climbing equipment to name a few only partially tongue-in-cheek suggestions. The most outstanding trauma surgery residents I've had the pleasure to work with all went on to make a living doing more lucrative lower-risk elective surgeries such as bariatric procedures and laparoscopic fundoplications. If we don't provide incentives to do the dirty work, not enough capable specialists are going to be around to do it.
Conclusion
I believe that my plan would make healthcare more accessible to Medicare patients while increasing the efficiency of the Medicare and Medicaid programs. It might decrease the cost of insurance to make it more accessible to the middle class while still maintaining the benefits of the current system for the insured. And I suggest that it would provide increased access to care of the uninsured. What more could you want from a healthcare plan?
Now I can badmouthHillarycare Obamacare to my hearts content without anyone asking me snidely, "well what's your plan then?"
Here it is...take it or leave it.
So what do we do about the struggling families who can't afford insurance, who don't want to pay for insurance, or who have chronic illnesses that effectively disqualify them from insurance plans? We definitely need a safety net for these folks. If we as a society are willing to pay for the care of the totally disabled, then we should be willing to support the working class when they need a little bit of help too. But as the brilliant Bill Whittle once wrote,
"I’m all for a safety net. It’s the safety hammock I have a problem with."
I think it's important to try to keep health insurance affordable via sensible but not overbearing insurance reforms, so that the healthier segment of the "struggling family" group can purchase private insurance if they choose to pay for a higher tier of healthcare. The sicker or lower-income members of this group should probably be covered by state or federal assistance programs instead. These folks don't need "insurance" anyway...they need someone else to pay their medical bills for them. They are the ones who need government handouts, not the rest of us, so I am against any plan that would force healthcare rationing on the population at large. And to answer a previous question by Ms. Alison Cummins, this same safety net (and the lower tier of care it represents) applies to the previously healthy/insured patient who because of financial or medical disaster finds himself unable to afford the higher tier of medical care he previously enjoyed.
Providing the care
Why not increase indigent medical access by increasing the role (and perhaps the number) of our outstanding medical training programs? We can expand the services provided by medical students and residents at the state and county level, using a sliding scale for charges based upon income. In my experience, indigent patients are typically appreciative of the relatively inexpensive and compassionate care provided by medical trainees. Insured patients, on the other hand, occasionally disdain such treatment. Despite the perception of a lower tier, the quality of care that is provided by housestaff and supervised by teaching physicians is often superior to that offered in private facilities. It surely isn't as convenient, but convenience is something you pay extra for.
I suggest that community indigent clinics could also be staffed on a rotating basis by physicians who have been disciplined by their state medical boards as a retribution for various medical misbehaviors. Volunteer physicians might also staff such clinics if they were offered some sort of tax writeoff and malpractice protection.
The additional cost to patients
Access to discounted rates for medical services do not come without a cost to the relatively indigent but able-bodied individuals. They should have to make some sacrifices in order to obtain their bargain medical care. They will have to pay their dues by allowing themselves to be on the teaching service, to obtain primary care by less-experienced (but supervised) physicians, and to accept the
Funding for these programs should be primarily the responsibility of the individual states
I suggest that each state should be primarily responsible for funding their own indigent and preventive medicine programs as they see fit, perhaps with some limited federal assistance or incentives. In Texas we fund our programs with sales taxes and property taxes, and we still don't have a state income tax. Teaching hospitals should establish or expand programs which send medical students and residents to satellite facilities in their state for clinical rotations. That would provide better access of care to uninsured patients, enhance the educational experience of budding physicians, and perhaps increase student interest in primary care. Expanding the concept of student loan deferment for physicians who agree to practice in these rural communities for a given period of time might be a good idea too.
EMTALA - follow the original intent
Acceptance of transfers of stabilized indigent patients who present to community hospitals should be expedited by state/county facilities so that definitive care can be provided by the funded teaching hospitals. If EMTALA is going to remain the law of the land, then the original concept should be followed rather than the tar baby into which it has evolved.
Tort reform can increase access and reduce costs
(edited for clarity)
One of the biggest crises in America today is the increasing difficulty of obtaining emergency surgical specialty care. Neurosurgeons, Orthopedists, Ophthalmologists, and Plastic Surgeons, for example, are avoiding ER call by giving up their hospital privileges to practice in free-standing surgical centers, leaving trauma patients in some areas with limited access to critically important services.
Optimally, the provision of free medical care (edit: such as that provided under EMTALA) should operate under the protection of Good Samaritan laws, thereby eliminating the prospect of malpractice torts and the extra associated costs of defensive medicine. If a patient is receiving free medical care, why in the heck should he be allowed to sue for a bad outcome? I think more (specialist) physicians would be willing to provide unreimbursed (emergency) treatment if they were immune from lawsuits. Alternatively, incentives to provide uncompensated medical care could be given to physicians by allowing them to write off the costs of their unpaid services as charitable donations.
"Self pay" patients should also be able to barter for discounted emergency or nonemergency care if they agree to sign a waiver releasing the treating physician from malpractice liability, or perhaps limiting the scope of such liability. With the current system, the patient is forced to pay for maximum liability protection for each and every encounter. High risk patients, therefore, often find it difficult to obtain medical treatment. Allowing more flexibility in this area is another potential way to reduce cost and increase access to medical services.
The trauma fund
Finally, a catastrophic medical fund should be established to help pay for uncompensated trauma care. And I would suggest that this money should be distributed by each state wherever it is needed most, such as a rural EMS system, an inner city trauma center, a LifeFlight program, or even to build additional county medical facilities. This could be partially funded by additional levies on automobile sales, drivers licensing, automobile registration, gasoline, traffic violations or various misdemeanors and felonies. Other options include specific taxes on the sales of motorcycles, skateboards, or rock-climbing equipment to name a few only partially tongue-in-cheek suggestions. The most outstanding trauma surgery residents I've had the pleasure to work with all went on to make a living doing more lucrative lower-risk elective surgeries such as bariatric procedures and laparoscopic fundoplications. If we don't provide incentives to do the dirty work, not enough capable specialists are going to be around to do it.
Conclusion
I believe that my plan would make healthcare more accessible to Medicare patients while increasing the efficiency of the Medicare and Medicaid programs. It might decrease the cost of insurance to make it more accessible to the middle class while still maintaining the benefits of the current system for the insured. And I suggest that it would provide increased access to care of the uninsured. What more could you want from a healthcare plan?
Now I can badmouth
Here it is...take it or leave it.
Labels: health care crisis
posted by scalpel at 3:32 AM
57 Comments:
So how many doctors out there are willing to work for free if they get immunity? How exactly does that work? You perform surgery on me to the best of your ability, I don't pay you, and you're happy because I don't sue you?
OK, where do we patients sign up for this deal? I bet that line's a lot longer than the one for the physicians who are interested.
For surgery, you'd have to go to the county hospital. You might get a discounted rate on a fracture reduction and cast though, or maybe a laceration repair. But nothing is free, nor should it be.
However, for a physician who is in the highest tax bracket, a state or federal tax writeoff of the full retail price of a surgical procedure or office visit might be an incentive that would stimulate some beneficence.
I like it! It irritates me to no end when I have to pay copays, insurance premiums, etc for people to get the same "level" of service that I do. Seeing that I am PAYING for it, why should I have to wait when they are not paying for it? I pay a premium. I should get premium benefits.
I also realize that our medical schools NEED people to practice on. I think this is an excellent idea. Need medical care but can't pay, visit the free clinic.
Personally, I don't like teaching hospitals. I realize that there are very good residents and medical students learning. I also realize that there are excellent teaching hospitals. However, when I am PAYING for it, I pay for the dr that has been fully trained. My pcp provides training to med students and residents in her private practice office. They always give me the option. Can medical student come and see you or do you want the doc. Everytime I say the doc. They just don't ask me anymore. That's another thing, if I am really sick. I want MY doctor to take care of me. I trust their opinion. I don't want someone that I have never met before taking care of me. It doesn't mean that they are not good, I don't know them. I have been on both sides (small private hospital with drs - have now and big university with med students - hated it.)
This provides benefits for everyone. Medical students and residents get the training they need. Uninsured get the medical treatment that they need. The community is served. Win win. The only problem is when you get people who don't pay medical at all that think they are "entitled" to everything that someone else pays a high price tag for.
I think drs would be more willing to provide some of their services pro bono if they can write it off on their taxes and/or get a reduction in loans and stuff.
I can see the point of waiving the malpractice insurance. Most drs truly do not wish to harm a patient. The only problem with this is I have seen first hand how a dr's negligence has changed someone's life. My mil had meningitis about a year ago. The family was told by the ER dr that someone had to stay with her in the room at all times or else they had to tie her down for her own safety. They kicked all the family out for the spinal tap. THEN LEFT HER ALONE. She because she had brain swelling and was nuts from the meningitis decided she had to pee (she had a catheter in). Got out of bed, fell and cracked her head and shoulder on a sink. They got her back in bed. Even in her crazy state she complained of bad head and shoulder pain. FOUR days later, they finally requested an xray. Her shoulder was shattered. She had surgery a couple of months ago. She ended up with a metal plate and 11 screws. She will NEVER have movement/function in her shoulder/arm again. The surgery was done to relieve her pain and give her "some" movement. So she originally went in for meningitis. She could have gone back to work after a month off. However, she is still out a year later due to three drs walking out and leaving her alone. She can't work (she was a secretary and it requires, lifting charts, boxes, typing, etc) and won't be able to go back to her job again (per her drs). It has completely changed her life for the worse. They have gone into debt, are going through their retirement accounts now, and have lost 1/2 of the family income. Not to mention all of the dr, hospital bills, and PT bills. So I understand drs that get sued for whacked reasons and wanting to waive the malpractice suits. How about when there is a legitimate reason for above where someone's life was basically ruined over something so careless. I guess the solution for that would be to have some kind of a fund that would compensate patients like my mil above?
Sorry this is long. Overall, I like the plan alot!!!!
I just wanted make clear about my previous comment anon 8:48am. I don't expect to be the first served in the Er waiting area. I don't go in demanding drugs or anything like that. I respect the drs and stuff. I do get irritated waiting 2 1/2 hours in the orthopedists office when I could have spent that time working. Then you have people who are NOT working and are using the system (car accident) to get disability and it wastes my time. That's what I meant when I said paying a premium for the service. For the record I see my ortho because of a car accident that completely tore my knee up. However, my butt was back at work 1 week after surgery when I was told it was 8 weeks out for it. I didn't have the leave to take it. I wasn't playing the disability game to not work. Like I said, they take care of those that are the sickest first. I don't play around with different pharmacies and stuff. ALL of my drs know what is going on with me and my pcp gets consults from them as well. I have never been rude or insulting to a dr or a nurse.
"But nothing is free, nor should it be."
So you didn't mean what you said earlier. We get it cheaper, but you get immunity? Who pays our bills when your negligence causes further injury? More free doctors? The taxpayer?
In this system, how does the physician make any money? Everyone would want free care playing the odds given how rare malpractice would be.
9:58 -
I'll reiterate my position for you. I never suggested that physicians would be lining up on the street eager to provide free medical care. They would require incentives. Please read the posts before you attack my proposals.
There are indeed people who get "free" emergency medical care, under the unfunded mandate of EMTALA. They present without ID or address, receive their free care, and disappear unless they need to file a lawsuit. I don't think those patients should be allowed to sue their treating physicians.
As you should be aware, specialist physicians are avoiding ER call like it was a rabid skunk, so something needs to be done to address the situation. I've tried to make an honest effort to address the issue, and I appreciate your interest in the discussion.
My various proposals also included suggestions that patients might be able to waive some or all of their tort rights in order to obtain discounted (not free) nonemergency medical care that they otherwise might not be able to obtain at all. If you have any specific concerns about this proposal, please speak up.
I did suggest that physicians might be willing to provide free medical care to selected patients if they were able to write off their charges as charitable donations. Whether my tort reform proposal would apply to those situations would be debatable.
I think you are really on the right track, here. Some of the questions raised are also good. One answer to who pays our bills when "your negligence causes further injury" might be some form of medical misadventure insurance that a patient could buy. After all, there is a risk anytime you go for treatment. If all the premium is paid by the doctor, there may not be enough money available to cover all the risk. Buy the coverage you need.
How does the doctor make any money? I would like to have sponsors, like NASCAR teams. If someone would pay me a few million a year in sponsorships, I would be happy to wear their logo while dispensing free medical and surgical care.
LOL.
I call the Budweiser scrubs. You can have Home Depot.
"I never suggested that physicians would be lining up on the street eager to provide free medical care. They would require incentives."
You originally did, but I note your edit. Obviously, though, the physician receives a benefit from access to the hospital, so they are compensated overall for that care, if not specifically from that care. So the physician does get a benefit from it, and presumably that benefit makes him money.
"They present without ID or address, receive their free care, and disappear unless they need to file a lawsuit. I don't think those patients should be allowed to sue their treating physicians"
So if the care is negligent, they should have no redress? Who picks up the tab for their future care as a result of the negligence if not the person who caused the harm?
As to waiving "tort rights", I guess I don't understand which rights you mean. The only right is to pursue a claim for negligence or an intentional act.
After re-reading that section, I can see where I might not have expressed my thoughts clearly, thus my edit. Sorry for the misunderstanding.
Yes, those are certainly issues that should be considered as we attempt to increase surgical specialty care in our nation's emergency departments.
Obviously, your suggestion that these disappearing specialists should be sufficiently compensated by the fringe benefits of hospital privileges alone despite the lack of funding for "no doc" patients is not holding much water.
So I eagerly await any other suggestions you might have to address the problem. I've already given mine.
Your 4th post on the subject... it takes some interesting turns. You are redeeming yourself a bit, though you are also contradicting yourself.
You have some positive suggestions here, but most of them are already operating. The rest aren't practical.
I don't mean to be critical, (well, maybe a little) but most of your suggestions seem to suggest that everyone else in the system should take a pay cut while doctors get a pay rise.
I am trying to be brief to make up for my last long response, so I will sum up my objections.
1. I am very happy with the care I've received under late-degree medical students, but don't even try to subject me to care by doctors that are being punished for having screwed up. There are too many problems with this to describe when I'm trying to be brief, just don't do it, I plead. I'd rather take the medical student unsupervised.
2. I object to any plan that INCREASES compensation for an alread overcompensated group while their system still makes more money from illness than from health. (and don't give me that "I worked long and hard to get where I am." crap, so did I.)
3. I really can't stand to hear that Medicare's preset prices are too low. If they were, then there wouldn't be so many physicians eager to suck the teat. And don't TELL ME that you can't bill your customers for the overage. I'm not officially "On Medicaid", but the financial assist I got on my last major problem came from them, and my providers are still billing me for the overage. (Even including one that came in late and is billing me for $3000 dollars for their participation in an ER stay of 15 minutes before I was triaged out to another hospital, more than doubling my cost for those 15 minutes to $5500.)
4. Doctors are specialists. You are illustrating that specialists should stick to their specialty. You have demonstrated that you don't understand economics, socioloy, or politics. These are areas in which my degrees focused.
Just try to be a good healer, and accept that you may have to settle for the Jaguar rather than the Ferrari, and your home may "only" be twice as large as you can reasonably use.
Mage
Physicians are already turning away Medicare and Medicaid patients (click here), and the problem will only continue to get worse unless we make some changes.
My present car cost $32,000, and I've never paid over $36,000 for a car. Sorry to pop your bubble.
What do you think about the Dutch healthcare system? I think it could serve as a model for the USA. Almost 100% of all people have health care insurance here. An extensive report on it can be found here: http://www.rivm.nl/bibliotheek/rapporten/260602002.html I hope you can comment on it?
2:31 -
Yikes, 192 pages!
It looks OK, but the Dutch tax rate appears to be 52% for all income over about $70,000 by my calculations.
Plus waiting times for specialty services appear to be a big problem, as in most other countries besides ours.
"Volunteer physicians might also staff such clinics if they were offered some sort of tax write-off and malpractice protection."
I love that idea, and I'm also in favor of tort reform.
I'd never sign a waiver releasing a physician from liability, but it's fair to sign one limiting liability.
Good ideas here, Scalpel--when are you running for public office? ;o)
About Bill Whittle--he seriously needs to update his blog. I've been checking back to no avail. Did you purchase his book?
Okay, so you're not TOTALLY heartless then, are you, Scalpel.
In some ways your schemes will obviously make more sense than Hillary's.
Because you're there. You know what the REAL complaints are with your current system, not just the politically popular ones. You have had to think through the things you see and consider how a system could better deal with them. IMHO, your scheme could work, where you live.
All the same, I'm happy to be in a different country, with a whole different (though related) set of problems.
Happy slagging!
I do one afternoon a month at a local free clinic. My (Catholic) employer covers my liability insurance for that as a charitable contribution. If they didn't, I wouldn't do it. On the other hand, if more physicians were willing to do something like this for one afternoon a month, it would add up handsomely. I really like the limitation of liability idea.
Excellent ideas, with a huge amount of thought on your part Scapel. Very appreciated - thank you!
I think Malpractice Tort reform is definitely in order BUT self-pay or indigent should be allowed to still sue but as you suggest, sign something limiting the suit. Suits are sometimes necessary regardless of ones ability to pay.
I also agree like the idea of disciplined physicians and for that matter nurses being assigned to idigent AND rural clinics as part of their reform. Gosh, you'd get these places staffed overnight!
MDs do not typically gravitate toward these type of clinics,partly because of the pay, the clientale and the fact that many are in less than desirable areas. It is the NP or PA that usually mans these places.
I also think that the general public needs to be made much more aware of the role of NPs and PAs and that the AMA needs to be more supportive of our role instead of always feeling so threatened by us. We offer a valuable service and are well trained at what we do. I am able to treat 85% of what comes into the ER without MD consultation and I do a damn good job at it - no doubt better than some ER MDs because my work is so closely scrutinized by the collaborating physicians.
Bartering for both Emergency Care and primary/specialty care should be a given but it is not. In fact, the non-insured patient WILL PAY MORE for care (if they have income) than the uninsured because they never get the discount that the the insured patient does. It is for this reason that I always instruct cash pay patients to ASK FOR A REDUCED FEE or the insurance rate - gosh, the uninsured cash pay pt should have to pay less overall because there is no middle-man to deal with.
Also, post some damn fees on the common complaints that can be seen in a clinic instead of an ER. You go to the ER as a patient and you have no idea until 3 weeks later that your kids ear infection was going to cost you $400!
Plus, health car providers just need to pay more attention to what tests and drugs they order. I know it is alot of defensive medicine but why can't you give phenergan instead of Zofran? Did you really need to do a Chem 20 on the man that vomited three times and is otherwise normal? Does every frikkin' headache or bump to the noggin need a head CT? Vag. spotting does not always need a CBC. What happen to to clinicians just using good assessment skills?
Just my one cent worth and appreciate everyone elses thoughts!
tk - I don't kiss ass well enough to be a successful politician, but thanks for the kind words. I bought Bill W.'s paperback.
NW - Excellent points, and I am embarrassed that I didn't mention NPs and PAs in my essay. I think they will continue to play crucial roles in whatever system we eventually end up with.
One detail that hasn't been addressed: If physicians practicing (and students training) in state institutions are protected from liability, how well-trained will those students be in defensive medicine? Aren't you setting up a generation of future providers to get eaten alive by the malpractice wolves?
Can anyone (say with military AND civilian medical experience) give some perspective?
I like your solutions, especially those relating to underserved care by medical students, physician full-value tax deductions, and performance incentives. However, one concern about the multi-tiered system is this- those who are poorest, working blue collar pay-per-day jobs, would wait the longest under your system because they pay the least. However, I would argue that these are the people who genuinely need to be seen quickly, as they are the most likely to be fired for missing any work. These are also the people least likely to go to the doctor in the first place because they feel like they don't have the time or money. Making them wait longer while rich countrymen are shuffled to the front will only exacerbate this problem. These people can't afford great medical care, really can't afford to miss a day of work, and especially can't afford to loose their jobs altogether.
Anonymous wrote: I want MY doctor to take care of me
Glad to see you have a doc that you have so much faith in thus refuse all Medical Students. However, for the most part, when patients see a medical student (not a resident) they also see the doc because the student is not licensed and the medical student should be running everything by the MD. Those patients actually seen by students often get better care because they are so thorough. I have precepted a fair amount of medical students (not residents), and while time consuming for me, I find patients really benefit from the time and refreshing attitude that a student has.
I work at County teaching hospital and I am always impressed by the residents - frequently picking things up that the attending did not - again because they are thorough. Yeah, they do over-order things, but for the most part, they are on their way toward being excellent diagnositicians.
I always tell my parents to get nursing and medical students/residents when they can because of the better care and less likely to have a problem just blown off.
Actually, I'd say a net is bigger and less likely to dump someone than a hammock....
Your idea of doctors under disciplinary review providing indigent care is a good one, because before long -- given the diminished training -- there'll be plenty of them.
And I guess if people in rural areas who can't afford care can't catch a bus to the med school (people who are bleeding aren't usually let on), they can hitch.
Seriously, though. You've given it a lot of thought, and I'm guessing if a plan is ever adopted (I hear they're setting up ice machines in Hell), it'll have some aspects of your ideas in it. And maybe some of mine. And -- don't be surprised -- of Hillary's.
kypdurron5-
If the poorest segment of patients suffer a serious acute illness, their waiting time for definitive care under this system would likely still be less than under a global socialized system (cough...Canada...cough...Netherlands).
Otherwise, for minor problems I would think they could be treated quickly and relatively inexpensively in the retail health setting.
Sid -
Docs these days (in Texas at least) are getting disciplined for many things that have nothing to do with malpractice. Not keeping up with CME, advertising violations, poor record-keeping, etc.
I've enjoyed reading your ideas.
I came across an article by John Stossel this afternoon and thought I'd post a link. I think he also makes some good points: Medical Competition Works for Patients
Nightwitch:
This was my whole statement: That's another thing, if I am really sick. I want MY doctor to take care of me. I trust their opinion. I don't want someone that I have never met before taking care of me. It doesn't mean that they are not good, I don't know them."
I have had the unfortunate situation of being in a life threatening situation with drs I did not know taking care of me at a teaching hospital. I know if I call my dr or go into my doctor, she knows my history and will not blow me off. She works through whatever with me. She has nailed the problem or issue every single time. My dr has also been an advocate on my behalf when dealing with a specialist. Maybe I am idealistic. My only experience with drs were military (till about 6 years ago) where you never had the same dr twice and recently civilian. I research my drs before I see them. I get personal experiences. Then I check out their credentials. I never said that medical students and residents were not good. They are. Just like there are good and bad drs. I went through two pcps before the third was a hit. I went through 4 peds before I actually decided family practice was the way to go. I love our pcp. My kids love her too. I value her opinion. However, from what I understand, she is one of a kind. They don't make them like her anymore.
My present HOME cost $30,000, and I've never paid more than $16,000 for a car... 11 years ago, and I'm still driving it. And you missed the fact that I meant that symbolically.
My bubble is intact.
My point is also intact. Doctors are overpaid. The system will not be fixed by allowing them to bill even higher rates. They are technicians. Highly trained and often hard-working technicians, but so is the carpenter that built your home, the plumber that set it up to be sanitary, the night stocker that stacked cans of peas on the grocery shelf so you could eat. And all are equally important to living a long and happy life.
I have solutions in mind, too... but they are just as unworkable as yours. I'm still working on them, even though the odds of a good solution that I come up with being implemented are the same as the already mentioned ice water in hell.
We all want health care reform. But even with the greatest economic, sociologic, and political minds in the world working on it, the problem remains.
I only ask that you have the humility to admit that you really don't know how to fix this any more than anyone else. And like it or not, doctors' compensation is not the problem.
Mage
ok-I've worked my whole life- for the government protecting your food so you could eat safely - ALL of you. Now I am ill and retired. I live on social security and a small pension. I have an illness that needs treatment by specialists. Because I am now poverty striken and on medicare you would have me treated by screw-up doctors who are being disciplined for god knows what and the inexperienced instead of getting experienced expert medical care that might possibly someday get me back to work. THANK YOU VERY MUCH.
I agree that doctors' compensation is not the problem.
Patients who think that they are entitled to the best care that (someone else's) money can buy are the problem.
Medical care is going to have to be rationed one way or another...how we do it is the ultimate question. And I already admitted the limitations of my perspective in the first paragraph of part 2.
Mage -
If doctors are just "technicians," the same as plumbers, would you expend the same amount of angst and energy you do ranting on some blog if a plumber didn't fix your kitchen sink properly the first time?
Somehow, I doubt it. Which means that doctors are somehow a little bit more than "technicians."
Look. I am not a doctor. I'm not married to one and I don't have one in my family. In fact, I'm a student nurse, living on loans. I will never make as much as a doctor BUT I will never have the responsibilty they do either.
There are many, many good doctors out there who have given their everything to become what they have become. Do I resent the bad ones out there who still make a fortune? YES!!!! Just like you. But I don't resent excellence being rewarded. I WANT excellence rewarded just as much as I want incompetence addressed and improved or removed and punished.
Profit is necessary in life. Profit is a requirement. Doctors, just like plumbers, must make a profit or they go out of business. The issue, though, is that salaries are largely based on what the market will bear. I think it would be great if plumbers made the same as doctors but it all comes down to whether the market would support that.
Bottom line - petulance and envy do not make strong rebuttals in debates. Scalpel has clearly taken a lot of time to think about and write down his ideas, many of which are really intriguing. His arguments are clearly not based on greed but simple economics and an acknowledgement of what motivates people of all economic backgrounds. Energy should be focused on whether his ideas could work and NOT whether one player in a system that is chock full of players (who are as susceptible as anyone to greed) makes more money.
Anon (boy don't we all just love anonymous commentors)
In case you haven't noticed, I mentioned that I've spent alot of time working on solutions as well, that I've admitted are equally unworkable.
What I'm objecting to here more than anything is the arrogance of a doctor stating that he can solve the problem if we just give him more money.
As a self-employed designer/builder of homes, I've spent time with people from many walks of life. I've found the arrogance of doctors to be second to none. (second place goes to any kind of engineer.) I've also found some doctors to be the kindest humans on the planet.
I just won't buy that doctors can solve this problem, nor will paying doctors more solve it. As a group, they have more money than they need. And I am sick of this attitude that, "I work long hours and I studied hard, so give me money." Many others work hard and studied long, and their work is equally vital to society.
Only doctors and software engineers recieve this level of compensation and feel so entitled to it. I am equally angry about the software engineers.
It's been mentioned that the feeling of entitlement of the patients is the problem. The feeling of entitlement of the doctors doesn't help either.
I just want the care I need to stay alive. I also want plumbing and heating for my meager home. I will (and do) pay everything I have not devoted to eating and heating (etc) on good health care. I won't listen idly to a lunatic who says that he needs even more money to solve the healt care crisis.
I haven't really listened very well since he said that
Mage
The establishment of proper incentives is more important to me than the actual number of dollars I might receive.
I'm sure I will make a comfortable living no matter what system of reimbursement I am paid under. That's one of the reasons I chose my specialty....there will always be a need for my expertise, and people will always be willing to pay me well for my services, no matter what happens in the world.
But unless physicians are given the same incentives that every other profession enjoys, people like you will continue to have difficulty obtaining our services.
Although there are definitely intrinsic rewards from altruism, you can't force it on anyone. You don't get to decide what I can charge for my services. You only get to decide what you are willing to pay for them. If you think I charge too much, then you are welcome to look elsewhere for the help you need.
Just like when you call a plumber.
Mage -
Scalpel's point is NOT that he and other doctors are the ONLY ONES who can solve the problem if only they are paid more. Really. Where did he say that?
As I understand it, one of the things he is advocating is the insertion of incentive and financial self-interest THROUGHOUT the health care system. Every player in the health care system ought to have incentives to choose wisely. As it is now, not everyone does and its effects are showing.
Listen, it is IRRELEVANT that you think doctors make too much money. Personally, I think a lot of home builders, sellers, and mortgage companies gouged home buyers over the last couple of years, and participated in the selling of homes for way, way more than the homes were actually worth and more than what the people could actually afford.
But guess what? It doesn't matter what I think. They can make whatever market forces will allow them to make. What matters is how I choose to behave in that scenario. I CHOSE not to purchase a home at that time. I CHOSE to rent and share a place with others so I could afford to live in an expensive city and afford the other things I needed at that time. Because I was responsible for the cost of my housing, I had incentive to find a solution that worked best for me. That is the point.
Are some doctors arrogant? Yes. Are they entitled to arrogancy? No. You seem to think that somehow, arrogant people should not be paid high salaries. Well, it would be fabulous if we lived in a world in which people who were unkind, unjust, and mean to humans and animals were paid less than those of us who do care but we don't. Personal weaknesses and faults are NOT what drive salaries!!!!
Listen, Mage. I WANT you to have the health care you need, not to just stay alive, but to thrive as much as your medical condition will allow. I do not want to live in a society where people cannot get good quality care. I want there to be a good safety net.
But the amount of abuse that hospital personnel and, more importantly, the American taxpayer suffer by people who feel they are entitled to the latest, top-of-the-line health care and yet are not required to contribute anything TOWARD their own care has simply overwhelmed me in the short time I have spent in the hospital setting. It will only stop when these people are required to have a financial stake in their own care.
In short, no one has the right to be arrogant. But I'll take arrogance based on education, skill, and experience any day over arrogance on the part of a person who is perfectly able to contribute to their own well-being but expects everyone else to do that for them.
"But unless physicians are given the same incentives that every other profession enjoys, people like you will continue to have difficulty obtaining our services."
What are these other incentives you're referring to? And why do you think other professions wouldn't trade them for the additional money you make?
"What are these other incentives you're referring to?"
I'm only going to say this one more time. That's it, so pay attention.
The ability to charge what one is worth on the open market.
Here's an example...let's say Medicare pays 40 dollars for a simple office visit. I have a waiting room full of patients who are willing to pay me $50 for the same visit. What is my incentive to accept any Medicare patients into my practice? If I accept ANY Medicare patients, I am forbidden by law from charging any of them more than what the government has decided that visit is worth. And yet the older Medicare patient is likely to be older, more complicated, higher risk, and more talkative than my other younger patients, so she takes twice as much of my time as the other higher paying patients.
So guess what? Even though your mom has Medicare and is surely a wonderful person with really important medical needs, I'm probably not going to accept her as a patient.
Now if I could charge her an extra $10 copay, maybe I would. Since I am an excellent doctor whose patients adore me, I'll have Medicare patients lined up trying to get into my practice despite the copay. But if the guy across the hall only charges a $5 copay, some of them might choose to see him instead.
Or she can wait three months to see the foreign doctor who doesn't charge a copay. Unfortunately, she can't understand him, he doesn't listen to her, and he rushes her out the door because he is seeing twice as many patients per day trying to make as much money as he can. His incentive is to see as many patients as he can, because his prices are FIXED by the government.
Get it? Buh bye.
But you do have that ability. You don't have to accept Medicare. You don't have to accept what this or that insurance company charges you. You make that choice because it guarantees you a pretty good standard of living if you take it.
So what's your complaint?
True, but I'm not the one who is having difficulty....patients are. I'll make a decent living either way, whether I accept Medicare patients or not. But for the Medicare patients who are having increasing difficulty finding a physician to treat them, they are faced with the choice of paying full price out of pocket to see a physician who doesn't accept Medicare, or perhaps settling for someone inferior who does (if they can find anyone at all).
I'm just trying to suggest other options, because it's always better to have more options. Right?
I don't know that they are settling for someone inferior. The public has no real way to weigh the skills of physicians. Nor does the lowest paid equal inferior care. In a true free market, a great physician with poor business sense or an extremely altruistic nature might do much worse than a poor physician with very good marketing skills.
There aren't different ways to provide healthcare, we're discussing different ways to pay for it. But at the end of the day, there are really only a few, which we're already doing. It's just that it's not balanced. The majority of you are wed to insurance and Medicare/Medicaid contracts.
The overhaul needed is simple. Establish a baseline level of care that the govt. will provide for all. I don't mean up to a certain dollar amount, but procedures and such. Maybe emergency care as well, and let the govt. collect from the individuals beyond the baseline when they receive emergency care.
Beyond that, let physicians contract as they do now. Some will want to take insurance, some will want to take private pay. Of those private pay, some will do payment plans, some will require cash up front, some will charge hourly, some flat fee, etc. And some will choose to do that govt. work we're talking about.
But that's the easy part. The hard part is establishing the baseline care.
Perhaps you should check numbers before you start throwing them out! Medicare allows $60.86 for a simple office visit (99213). Of that allowed amount, Medicare will pay $48.69 and you bill the remaining $12.17 to the patient. If you are willing to see the patients who are willing to pay you $50 instead...you are shooting yourself in the foot. I'm not exactly sure why you are harping on Medicare (medicaid is another issue altogether), since ALL third-party payors use Medicare allowed amounts as the standard. Some pay a little more than Medicare, but its not much more. So, you really should complain about the entire insurance system...which I will agree needs an overhaul. However, your overhaul leaves much to be desired for a large portion of the country.
This is a hypothetical discussion...I was just throwing out numbers, not trying to be exact. I don't really care how much they pay, that isn't the point. The point is that if I provide a service that some Medicare patients think is worth an extra $20 (or $40 or $100) to them, then why can't we make such a deal? Let the government pay their part and let me bill as much over that as I can command on the open market.
If I'm charging too much, patients won't come see me, and I'll reduce my charges until a balance is reached. Or I'll offer more services to attract more patients willing to pay a surplus.
Is it really better for these patients if I stop taking Medicare patients altogether? They have already paid into the system, let them use the benefits as they see fit.
I am on Medicare and I can promise you that I DO get billed for what Medicare does not pay. I also agree and wonder why there is always this comparison between Medicaid and Medicare?
Just yesterday I received a bill for 86.00 from one of my doc's which was the difference between what he charged and what Medicare paid him. And it was refused through my secondary insurance of AARP. Hell I even pay 96.50 per month for part B, 63.00 per month for Part D, 258.00 per month for AARP, and many many co-pays each month. In addition I think we worked for about 45 years and paid into this program with each and every pay check we earned.. Stop calling it a free program and stop comparing it to medicaid.
"I am on Medicare and I can promise you that I DO get billed for what Medicare does not pay."
That's illegal.
Again, I'm not really complaining about Medicare rates, and as an ER doc, I'm personally stuck taking whatever they decide to pay me, and honestly I'm grateful for it.
Yeah, I could open up my own free-standing ER and charge whatever I want if I were that unsatisfied with the rates, but I'm perfectly happy with the system as it stands today.
Many patients are having trouble finding primary physicians who are willing to accept Medicare patients, and this problem will only get worse as the Medicare-eligible population grows. My post was an attempt to come up with a suggestion to give these patients more options.
Please take it as such rather than an attempt by me to squeeze more money out of them.
If a patient on Medicare can afford to pay extra, then they most likely have a secondary insurance. Those who don't have a secondary don't have one because they can't afford it...therefore, can't afford to pay extra either. As for families picking up the slack...many do. My "Medicare granny" gets $100 a month (each)from 4 of her 5 children...three of whom are paying for college educations for their children. The grandchildren take turns picking up her rx meds each month since she can't even afford them with Medicare part D. Oh...and she doesn't qualify for Medicaid (medi-cal since this is CA) because she owns a "stick home" (no foundation) that is worth nothing except the cost of the land it sits on. Perhaps you'd like to return to "the good old days"...my family would be happy to give you a chicken at time of service and deliver some fresh milk to your doorstep a few days later.
Scalpel- your ideas are well thought out and I applaud your efforts. You definitely have more patience than I. I am ill reading the comments of Mage and those who think that doctors are overpaid. Mage is a homebuilder and boasting about how little he paid for his own home. That's like a doctor boasting about how little they have to pay for medical care. Duh! I wish you the best. I am glad that there are caring physicians like yourself that are thinking about these problems. (No, I'm not a doctor.)
Scalpel, you aren't making sense here. you say it is illegal to bill us for balances that Medicare wont pay and yet many many of us have secondary insurance to cover such things. Secondary ins is very expensive. more so than the medicare premiums. Why would we be paying out that money if Doctors had to accept and did accept what Medicare gave them as paid in full?
To Cindy above who got an $86 bill from her doctor:
If Medicare paid for a portion of the original bill sent in by the doctor (usually 80% of the Medicare-allowed fee), then the AARP Medigap supplemental insurance must pay the other 20%. The problem in this case is not with the doctor, it is with AARP Medigap.
Are you certain that the doctor's office actually billed AARP for the other 20%? If I were you, I'd gather together all the paperwork for this bill, and start making phone calls to figure out who has paid for what.
As for my father's 'free' Medicare: He has $78 taken out of his Social Security check automatically to pay for Medicare Part B, another $152 a month for AARP Medigap insurance, and another $25 a month for Medicare Part D drug insurance. HOWEVER, with the perverse (but totally legal) way that the drug plans have been set up, we will be paying $3200 in drug bills anyway, because of the donut hole type deductible taht kicks in once your drug costs reach $1500.
At any rate, my father's total out-of-pocket costs this year will be $6300. Which is a far cry from free.
"My post was an attempt to come up with a suggestion to give these patients more options."
The only way to give them more options is to pay primary care physicians more money. That's what will motivate physicians.
Let me guess scalpel, you work in a private community hospital in general a middle to upper middle class suburb.
scalpel said...
I have worked in two of the largest tertiary referral centers in the state, I have worked in a semi-rural ER that served a combination of mostly uninsured and middle-income insured plant workers, I have worked in a few suburban free-standing urgent care centers, some which were located in very upscale areas and some that were more barrio.
Interestingly, I have never turned a patient away from any of them.
I'd be willing to donate my time to the medically indigent if I weren't going to get sued for the pleasure.
I would like to make a point to the readers who think it is a bad idea to funnel more money into the health care system (not just doctors in particular). Hospitals that serve the poor shut down because they go into such debt. I have seen uninsured patients in the ICU rack up millions of dollars in costs over the course of a few months that the hospital just "absorbed." We are forever seeing patients in the ER who come in for preventable things (seizures after not taking their medications, drunk and fell down requiring a head CT and plastic surgery, chronic pain but didn't make a doctor's appointment for a refill, missed dialysis for two weeks and required ICU admission, etc etc) and we give out millions of dollars of "free" care to anyone who comes to us and cannot pay. That's fine, our ER gets by. But lots don't, and when those hospitals close, the patients there either have nowhere to go, or they shift to another hospital and start draining that one of resources. No one is served well by this. Establishing guaranteed primary care (via scalpel's idea of free clinics or another) and cutting down on expensive emergency services for non-emergent conditions are two great ways to ensure that any person can get more timely care and hospitals in poor payor mix areas will not disappear so rapidly.
As for doctors' pay, none of us are going to starve and we know it, as scalpel has alluded to. I currently make around 45K/year as a resident, which is pretty normal. When I'm done, I'll make something like 200-250K/year, which seems bizarre to me. The reality is that we lost one of the youngest, healthiest decades of our lives getting trained and spend 30 years making substantial loan payments. We also make huge yearly payments to maintain malpractice insurance. I think school loans plus malpractice is pretty close to 40-50K per year. So please bear that in mind when discussing doctor salaries.
I mostly agree. And the idea of limiting malpractice is beautiful. In San Francisco, a couple young thugs just won a suit for $900k after being attacked by a tiger. Not medical malpractice, but another example of outsized payouts. Our courts value people's lives far, far above the value that employers and insurers place on a person.
I propose that malpractice suits should be limited to a total of 6x income or $300k, whichever is higher, plus actual expenses. Patients can choose to purchase a higher limit, so CEOs whose lives are quite economically valuable can still receive appropriate coverage, but at their own expense.
But I don't think free care=no recourse against malpractice. A patient has a right to expect quality care that leaves them, at worst, no worse off than before/without care. Lower malpractice limits are fine, but telling a negligently paralyzed patient to suck it up because care was free - no dice. And it would be bad brain maintenance for a doc to practice "good enough" medicine on the poor when he/she returns to practicing "excellent" medicine on paying clients - sloppy medical habits should never be accepted because they become just that, habits.
Night Witch is spot on with posting prices. That is such a pet peeve - as the patient, I am most able to control costs, but I am not allowed to KNOW the costs! I had a doc who billed for a chronic condition on every visit, though she was totally unqualified to do anything for it and couldn't even pronounce it (her advice was always "keep doing what your specialist says") but I didn't know she was billing for it due to cryptic billing codes.
In order to live by my convictions, I recently switched to a %-based cost-share. I tried being an informed, cost-conscious patient, and the system won't let me. Docs get pi$$ed if I ask them what something costs and if it's really necessary, and they label me non-compliant just because I ASKED.
Dr. Offices and labs won't quote prices over the phone (they say it depends on my insurance, but they won't tell me what price my insurance has negotiated) and if I ask as if I were a cash patient, the prices are so ridiculous I cannot believe there is any relation to reality. Pap smear+annual exam quoted at $250-400, not including lab fees!
If a low back pain patient limps into ER at 7 pm and sees the price is $400, will she wait a day to see her doc for $150? Some would. Every industry seeks price obscurity to maximize profits. That's why mechanics are required to provide written quotes and why in-home sales have a 3-day right of recission. Medicine is one of the few professions still allowed to conceal prices until after treatment. It's hard for the invisible hand to optimize spending when the consumer is prevented from making choices with full knowledge of costs.
"The ability to charge what one is worth on the open market."
Physicians have that ability. They do not have to enter into the CMS payment scheme.
I'm a total liberal, but I'm also an ER nurse in a community hospital in a diverse city.... and I like your ideas. Thanks for the food for thought.
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