Cheap medical care.

[Everskyward]

One example, other docs often want to send a demented nursing home patient for a very expensive procedure even though they are not likely to have an improved quality of life since a family member "wants everything done". The best option would be to keep the patient at the local hospital and treat conservatively but you can't refuse accepting the patient without risking a lawsuit.

I know and have known quite a few elderly people, some of whom have passed on and some who haven't. However none of them or their families, that I know, have "wanted everything done". Most ended up with DNR orders or hospice care. Some actively decided to stop taking medication except for pain medication or have refused food and water.

 

[Gary F]

As to the "global cost structure" question, it is just the wrong question ... or too short term in scope to be addressed. The global cost structure won't change a bit in the near term because the path we've picked simply does not structurally change the demand profile or the incentives.

The recent changes to healthcare will, eventually, put an upper cap on the spending of OPM. Think Medicaid ... limited budget and, at the individual level, unlimited demand. The result is that it is becoming ever more difficult for Medicaid patients to find service providers (there can be no arguing this point). If you take this to a national system, you get the exact same results.

So as our debt approaches 100% GDP and are taxes become "too high" (whatever we collectively decide that is), we will be FORCED to answer the ultimate question - HOW WILL WE RATION MEDICAL CARE?

Today:
* The wealthy - I'm going to see my doctor for this problem and then find out who the best damn specialist is and see him/her!
* The middle class - I hope I don't canned at work because the treatment cost for my daughters (insert problem) is expensive, but at least she's being cared for well.
* The poor - I've got blood in my urine again, but this time it looks bad, maybe I should go to the ER because I never got around to seeing that doctor who accepts Medicaid 30 miles away.
* System - health care by lottery

Tomorrow (after the new system is in place):
* Everyone - Yippee, I get to see the doctor, get the best medical services and it's free!
* System - damn the torpedoes (budget, debt), health care for everyone!

Day After Tomorrow (after new system in place for a few years):
* Everyone but the rich - What do you mean, a CAT scan is going to take 4 months to get scheduled! I'm sick, I need help!
* The rich - Wow, this new private hospital concept in Cancun is great. A vacation and a tune-up. I really like the idea of the concierge health care plan administered out of the Cayman Islands. It's expensive, but everything is covered, I have access to the worlds best doctors with nothing more than a call and a brief flight on the private jet and I can afford it.
* System - health care rationing by queue (unless you are rich)

So the inevitable is clear:
1) We will ration health care.
2) The rich will always get the best service.

When we collectively accept that reality, we as a nation can finally have an intelligent discussion.
* Do you want to trust the people who brought you trillion dollar deficits, the TSA and the Bob Hoover incident, or do you want to harness the innovation that made this country great.
* No matter what, the rich will get richer, and you and your family won't get all the medical services you want.

What path forward - government bureaucracy or capitalism driven solutions with all its unfairness and inequity? Answer that question and we can discuss global cost structure.

P.S. - The US drives the global health care cost structure. We're the innovators and the consumers. That great red menace China did 200,000 orthopedic operations last year. The great state of IN did more than that last month.

You are good. I will write more later as I am too busy today. One overlooked opportunity is to improve the efficiency of the practice of medicine. Medicine is currently practiced in a very cost inefficient manner. I know how great improvements can be made however it is not practical for a variety of reasons to attempt to do this now. The need for efficiency improvements will become more obvious in the future. I expect to make a really good living as a consultant implementing efficiency improvement programs.

 

[Gary F]

I know and have known quite a few elderly people, some of whom have passed on and some who haven't. However none of them or their families, that I know, have "wanted everything done". Most ended up with DNR orders or hospice care. Some actively decided to stop taking medication except for pain medication or have refused food and water.

This is probably the result of a population bias. It depends a lot on the educational and religious background of the family members. People who are less educated tend to have more unrealistic expectations. Sometimes it is the primary provider which is pushing to inappropriate care. I do this for a living so I see it all the time. My most recent encounter (30 minutes ago) was about a 91 y/o lady with a very bad heart. The hospitalist wanted me to explain to the family why we can't just take her to the cath lab and make her better. The problem is that in many other hospitals she would already be in the lab having a $30,000 procedure which would not help her in the long run.

 

[Doggtyred]

It depends a lot on the educational and religious background of the family members. People who are less educated tend to have more unrealistic expectations.

I can agree with this statement whole heartedly.

 

[bbchien]

I've QUIT the system it's so bad.....and the future sytem is totally unworkable.

 

[Bravo3]

I've QUIT the system it's so bad.....and the future sytem is totally unworkable.

Personally, I plan to strap on a tail and start sniffing people's butts. Vets are downright affordable. Just saying.

 

[jsstevens]

The hospitals try to get the money from insurance because they can't refuse services to people that have $0

The hospitals also (very likely, I'm not involved in health care) are setting the prices high because they know that the insurance companies will negotiate (or as some would say demand) lower prices. This allows the hospital to lower the price substantially (which the insurance can report as savings) without lowering the price so far that they lose money.

John

 

[Doggtyred]

The hospitals also (very likely, I'm not involved in health care) are setting the prices high because they know that the insurance companies will negotiate (or as some would say demand) lower prices. This allows the hospital to lower the price substantially (which the insurance can report as savings) without lowering the price so far that they lose money.

John

They do. Its a balance. Insurance company says "this is what we will pay". Hospital takes it or leaves it.

With just a few big providers, hospitals turning their back on providers can make a big dent in business.

But if all the hospitals (or enough if them) don't take a provider, then in the end the provider loses market share.

 

[Everskyward]

My most recent encounter (30 minutes ago) was about a 91 y/o lady with a very bad heart. The hospitalist wanted me to explain to the family why we can't just take her to the cath lab and make her better. The problem is that in many other hospitals she would already be in the lab having a $30,000 procedure which would not help her in the long run.

I would say that is nuts. Why would you want to put your loved one through some procedure which is bound to be disruptive to their life when it's not going to help? But you are probably right about population bias. The people around me have always drummed into me that they don't want to live prolonged lives in pain when there is no quality of life.

 

[Gary F]

I would say that is nuts. Why would you want to put your loved one through some procedure which is bound to be disruptive to their life when it's not going to help? But you are probably right about population bias. The people around me have always drummed into me that they don't want to live prolonged lives in pain when there is no quality of life.

The son of a 94 y/o man filed a formal complaint against me with the patient representative when I decided against taking his dad to the cath lab. I did a through evaluation and decided that the risks outweighed the benefit. Fortunately, the hospital committee reviewing the case agreed that what I did was reasonable and appropriate.
In other cases physicians may be influenced by the profit motive and some really believe that doing more is usually better. They may offer all options but seem to nudge patients and families into a more aggressive (and profitable) approach.

 

[Doggtyred]

The son of a 94 y/o man filed a formal complaint against me with the patient representative when I decided against taking his dad to the cath lab. I did a through evaluation and decided that the risks outweighed the benefit. Fortunately, the hospital committee reviewing the case agreed that what I did was reasonable and appropriate.
In other cases physicians may be influenced by the profit motive and some really believe that doing more is usually better. They may offer all options but seem to nudge patients and families into a more aggressive (and profitable) approach.

Glad to know that physicians are still able to refuse to perform procedures or treatment that is of questionable or minimal benefit.

 

[Gary F]

Glad to know that physicians are still able to refuse to perform procedures or treatment that is of questionable or minimal benefit.

A physician can't be forced to perform any procedure on anybody but if you don't:
1. You give up income, possibly a lot.
2. The patient, family and referring physician may be very disappointed.
3. If you get sued good luck convincing a jury that if was better not to do a procedure since it might have helped even if it really would not.

I give patients all reasonable options and explain the risks and benefits and let them decide. Often the referring provider has told them they should get a certain procedure then I have to explain why I don't think it is a good idea. Next time the referring physician will send the next patient to somebody who will do the most aggressive approach.

 

[Everskyward]

A physician can't be forced to perform any procedure on anybody but if you don't:
1. You give up income, possibly a lot.

This is something that I feel needs to be corrected somehow. I think that the profit motive should somehow be taken out of the equation as far as decisions like this are concerned. To equate it to aviation, I read something once which said that it enhances safety to pay pilots a salary instead of hourly because it takes the personal financial gain out of the decision making process. If you decide against the flight you are not losing money. Both pilots and doctors would probably tell you that, of course they are not influenced by financial considerations, but I think there is a subtile or not so subtile pressure there, depending on the person.