Centerfield

Chris, as a doctor are you comfortable with the notion that the study about nursing care rings true? Just wondering if the anecdotes of your experience back up what the study says.

I bet that a lot of people have stories like yours about what's covered and what isn't that don't make much sense. For example, I have flat feet which led to some plantar fasciitis, and the only thing that wasn't covered was the orthotic shoe inserts that helped more than the visits, examinations, medication, x-rays, and physical therapy. Not that any of that other stuff was unnecessary per se, but you get my point.

Here's another...I am not covered to have laser vision correction, but I am covered for an annual exam and new glasses every 2 years. Which has a higher lifetime cost? I'm only covered for 2 teeth cleanings per year even though my dentist recommends me as one of the people who could really use 3. But I'll likely be covered for any adverse affects stemming from lack of treatment.

I agree with your point that to some extent the healthcare industry's profit imperatives channel the system astray from what the true imperatives should be, the most health for the fewest dollars. But that is, as you also note, related to not being willing to bear costs for items of questionable efficacy. Someone somwhere has counted the beans on all the things I mentioned, as well as your diabetes example. They get stuck asking "how often does a diabetic follow a podiatrist's or nutritionist's instructions in the rigorous way required to stave off future complications? And "to what extent is a serious treatment such as amputation actually preventable as opposed to being only delayable?"

The unavoidable fact is that it is likely to remain true that individuals will have to be their own advocates and their own case managers.

Here's where I say something Pat will love me for...and Chris may hate me for...if you think a hospital is giving you the run around, get a lawyer to write you a polite but pointed letter expressing this view, one which briefly describes your grievances and the ways in which you feel the hospital has failed you, and suggesting that should the negative outcomes which you fear come to pass, you'll consider these outcomes to be the responsibility of the hospital. After all, you've taken the time in this letter to put them on official notice about the problem, and how willing you are to cooperate in good faith with the hospital to resolve the issue BEFORE anything really bad happens. This makes it much harder for hospitals to claim they were duly diligent and that the fault was that of the patient. Then sit by the phone and wait for all those doctors to start returning your calls, and all those administrators to express their heartfelt desire to work with you. It's like effing magic!

They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.

Bingo. The money is not in preventative medicine, the money is in treatments that could have been avoided by preventative medicine. As a result we only spend about 2% of our health care dollars on prevention--and 20% on system billing overheads, much of that dedicated to avoiding payments.

It gets worse. Corporate consolidation among both for-profit and non-profit providers means that in hospitalization, a few providers control the national hospital market. On the payor side, regional oligopolies lock the overhead structure into place, while reducing availability of access through exclusive provider contracts.

A proposal that appeared in the Journal of the AMA two years ago deserves some SERIOUS consideration.

To elaborate a bit more: With health insurance so firmly linked to employment, and with employment becoming increasingly less "career" and more temporal, there's just not that much incentive for insurors to emphasize or pay for preventative care. Statistically, people now switch jobs and employers every few years. The "pay off" for preventative medicine is usually several years down the road, or longer.

So instead of paying for the preventative care, the issue is pushed down the road to await the patient's next insuror, the one on the hook when the acute crisis hits. The payor is avoiding the preventative care cost, knowing that the acute care cost that would have been avoided will (statistically speaking) fall on someone else.

On the provider side, there's simply not that much money in preventative care when compared to the margins for acute care. Straight rent-seeking. Most doctors want to practice good medicine. But they also want to pay their bills and take vacations, etc. They didn't go through 10 to 15 years of training and stack up $150K or more in student loans to earn McDonald's wages.

You can't get payors or providers to concentrate on preventative medicine when it actively costs them money to do so, and there's simply no major incentive under our current structure to do so. The only area where preventative medicine gets much of a workout is in public health programs for the poor and uninsured.

So instead of paying for the preventative care, the issue is pushed down the road to await the patient's next insuror, the one on the hook when the acute crisis hits. The payor is avoiding the preventative care cost, knowing that the acute care cost that would have been avoided will (statistically speaking) fall on someone else.

I'm thinking in terms of game theory here. I would assume that the insurance companies are way off the Nash Equilibrium. Everyone ends up being someone else's someone else.

Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to assure this right.

I must have missed that in the Bill of Rights. I don't remember it in the Ten Commandments either. Healthcare is a need, not a "basic human right". The avoidance of personal responsibility for your own health inherent in most of the fixes offered makes the likelyhood of any meaningful reforms impossible. Its the mindset that needs changed.

I'm sorry when someone is terminally ill. I've had close experience with it (as a lot of us have). But why should I pay part of a $100K last week of life hopital bill? As others have pointed out the system is heavily weighted to useless payments, when the real benefits come from upfront actions. And the ones that really make a difference are when people take personal responsibility. We need to change the entire mindset if we want to make a difference. Push yourself away from the dinner table, skip the cigarettes and booze, and get on a treadmill.

We're all going to die. That's a basic human "right" that we are born with. We can make social contracts with each other to try to avoid it as long as possible, but without the personal resposibility clause they will always be unaffordable given the oddity that while individual human life is priceless, human life as a whole is cheap.

We can all come up with financial horror stories about modern health care. If you haven't lived through one, you certainly know of one. It's easy to say that we should learn to die with dignity, hard to say that yourself or a loved one needs to recognize when it's time to acknowledge the odds and pack it in.

It's easy to blame the payors for cost-shifting, or the providers for rent-seeking, or the patients themselves for personal neglect and end-of-life selfishness and against-the-odds demands. And it'd mostly all be true. But standing around in a circular finger-pointing squad doesn't improve or reform the system. If there were a single true scapegoat, we could slaughter the goat and move on. There isn't, so we can't. NO reform is possible without ALL actors giving something up. And none of them want to give up anything. Instead, they all want more.

We have met the enemy, and he is us.

The government fundamentally distorted the market when it allowed employers to deduct health insurance provided to employees but did not allow employees to deduct such insurance when purchased themselves. There are additional government-imposed distortions at a variety of levels, from regulations limiting small businesses from combining to purchase health insurance at better rates (due to a larger group) to legislative imposition of specific diseases or conditions which must be covered.

All of these distortions should be removed as a first step toward reform. The market can fix a lot of these problems if government would just get out of the way and confine itself to helping the indigent obtain coverage with some type of tax credit or other program.

Dennis, who are you quoting? Was it embedded in the Times article, or are the italics just a rhetorical device for a notion you want to refute?

Seems to me that healthcare is a basic human right to whatever extent that we, as a collective democracy, declare it to be. And we can make such declarations not only in the constitution but also by the sum total of whatever policies we establish. And that sum total will imperfectly approximate how we feel as a culture.

The problem, of course, is that we irrationally believe (subconsciously and collectively as a culture) that ideally we should all live forever, so failing that, we should pursue lifespan maximization and ignore or redistribute the costs away from ourselves by any means necessary. You or I may not believe that, but the system collectively functions to foster it, and it does so because collectively many or even most people believe that anyone who is sick should receive healthcare regardless of whether they can pay for it...

And coincidentally or not, it's mostly those with substantial assets to protect and who have chosen to live especially responsibly who advocate an approach in which it is declared to be crucial that one receives high rewards for taking individual responsibility. People who feel that way are bound to get very angry from time to time if they live in a social democracy, which is what America is. We're not a republic, at least not today.

Brian,
It was from the article. And it is a notion I have a hard time with. Not just healthcare, but all sorts of "human rights". Social contracts have become confused with human rights IMO. Just because someone legislates something doesn't make it a human right. Once it enters the public understanding as 'basic' it make it very hard to compromise.

Agree with Tully that it's easy in the hypothetical, but when it is personal it is a different matter.