Tooting My Reform Horn
I almost forgot. I’m the opening line in the latest Stanford Medicine magazine. Always happy to serve as the big, fat Commie Pinko.
or
I almost forgot. I’m the opening line in the latest Stanford Medicine magazine. Always happy to serve as the big, fat Commie Pinko.
This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.
I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!
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Neat article, another one for my bookmarks and later re-reading. Not only is the current healthcare system a nightmare for the uninsured, it’s an overpriced mess even for those of us with insurance. I’m a relatively healthy 25 year old, with a decent enough middle-class white collar job (Computer Technician, ~$30,000 yearly); my job’s got pretty good insurance; Despite all that, when my gallbladder rebelled last year and I needed surgery, I ended up with over $2500 in out-of-pocket medical bills. While I’ll be the first to admit that that’s no tragedy compared to some poor uninsured person not being able to get care at all, $2500 is still a -lot- of money for a guy living paycheck to paycheck, trying to pay off student loans and make something of himself. If people like me, who are fortunate to have jobs and insurance still feel really stung by the system, then that’s just further proof of how broke it is. Pardon me for rambling, I’m a big fan of your blog, I came across it originally while researching Melarsoprol for the Wikipedia article I wrote on it (only a stub now, hope to update it more later.), and it’s been an entertaining and enlightening read.
- LM
It’s absolutely a tragedy, LM. And your case is just the type of example that opponents of the reform effort don’t want to hear about. They want to hear about fraud in the system, and people abusing the system. They don’t want to hear about someone who, for no other reason besides random chance, got sick, and had to pay an enormous 8.3% of his or her yearly salary to cover a medical procedure!
Thanks so much for reading.
Why wouldn’t your insurance cover it, if you don’t mind me asking?
That’s the normal copay, apparently. Just as an example (since I happen to have the paperwork for it sitting here), my initial visit to an emergency clinic associated with a major hospital, from when I first noticed that I was getting quite sick, came to a total of $528. My insurance covered $420, leaving me to pay $108 out of my pocket. This same sort of split was the case throughout my experience, from the surgery, to the hospital stay, to the anesthegiologist. All those copays add up -very- quicky.
Thanks for your reply, and keep up your writing (well, as much as your busy med-student schedule allows), it’s informative. As an armchair medical geek, it’s nice to learn from more than just TV shows and being halfway to a bachelor’s in bio. :)
- LM.
A public health care system leaves a lot to be desired – immensely long waiting times for some procedures, difficulties in finding a family doctor, constant haemorrhaging of health care professionals to greener (and warmer) pastures – and it’s inherently unstable, requiring constant twiddling and adjustment. But hearing of someone in this day and age in North America losing their vision because they couldn’t afford treatment – that’s like getting an update from the early 1900s. I guess that this shows you what life under socialism does for you – things like that just don’t happen under a publically-funded system.
LM- your experience was not a “tragedy,” it was a miracle. You very likely were having the worst pain in your life from a sick gallbladder. You went to a local ER. Highly trained physicians, nurses, and techs were there because you needed them. I’ll bet that you were definitively cured within 48 hours of when you hit the door of the ER, and back to work within a week. Try that in any of your socialist paradises. You can quibble about the cost (8.3% is a good chunk, but “enormous?” Come on, Graham, a little perspective please). The reason that your care was so expensive is that a part of it goes to pay for the care of “some poor uninsured person,” who, contrary to your statement that he is “not being able to get care at all,” shows up in the ER just like you did, and gets the same care you did, for free. Sure, the poor guy gets the full bill, for $20K or so, but typically throws it in the trash, and there isn’t much the hospital or the docs can do about it.
The care that you and Graham complain about costing so much was not available to anyone, not kings, queens, billionaires, or presidents, a generation ago. There are entire countries in Africa and Asia where your operation is not available, even today, even for the rulers of the country, unless they want to leave their home country and fly to Europe or elsewhere. Yes, I take out gallbladders for a living (among other things). The amount I get paid varies from zero to two thousand dollars. I generally don’t know how much I’ll get paid until 6 weeks after the patient is cured, and every one of them gets the same level of care. As I said, a little perspective, please.
Actually, JB, first I went to an emergency clinic associated with a major hospital, where they poked, prodded, took fluids, said they’d run some tests and call me back if they found anything, but to go to an ER if I felt worse. I did indeed feel -much- worse the next day, so I went to the ER of my hospital of choice. My experience from then on was, indeed, quit e well handled. That original clinic, though? They never got back to me with my test results, never forwarded anything to the other hospital, nada. Yet I still owe them their $108. (In addition to the $420 they got out of my insurance.); Something’s broken there.
And correct me if I’m wrong, but can’t private hospitals refuse care to the uninsured? See, the hospital I used was private, not any sort of county/city/regional facility; so I think it’s untrue that any of my costs went to paying for some uninsured person’s care, since I believe they can turn away the uninsured. Mind you, I get this impression from watching ER, not the most reliable source, but they regularly make a point in the show of doing the whole ‘We’re a county facility, so we have to treat (uninsured person), but (soandso private hospital) can toss them out.’.
And finally, if you’ve already gotten say, $1500-$2000 out of my insurance company for taking out my gallbladder, do you -really- need the other $500 or so I’m being asked to pay out of pocket?
(Oh, and PS. I was in the hospital for a week, but not back to work for another week and a half after that. No fault of the docs or techs though, my liver decided to get in the way, so they had to do the old slice-and-dice style surgery instead of the laproscopy. )
Actually JB, I can guarantee you that in Canada (socialist paradise? even you must know that’s wholly inaccurate), LM would have had the exact same standard of care for his cholecystectomy, and it cost him much less. (This is not to say that it was free; it was paid for by his taxes and his employer’s.) Triage still exists in Canada. If you need surgery immediately, you get surgery immediately, just like you do here. It’s *elective* procedures that are different.
I am fully aware that the level of care today is much, much improved over that of a generation ago; what’s your point? I am fully appreciative of the level of care that we have in the US, in comparison to other parts of the world, but in no way does that mean that we shouldn’t strive for the best health care available to us here in the US. I don’t get your logic there.
And JB–in those socialist paradises you talk about, you know exactly how much you’re going to get for each cystectomy, and if you *don’t* get paid that amount within 30 days, the single-payer is required to pay you interest on it. Are you saying you’d much rather live with the current system? Even you don’t sound too pleased by it.
Taking L. Moore’s points in turn:
You apparently first went to an urgent care clinic. They did some basic tests, found nothing urgently wrong, and a properly told you to go to an ER if you did not get better. You very likely had biliary colic, and possibly some cholecystitis, which may or may not show an elevation of the white blood cell count. It would be unlikely for an urgent care clinic to have an ultrasound imaging device, which is the best way to diagnose gallbladder disease. That’s why they recommended the ER visit. You ask why they did not get back to you with the test results? Most likely, they were all normal. Federal law prohibits them sending the results to the other hospital, unless you specifically request this and give permission in writing. They are required to give you your own results if you request them, and they were negligent if they did not do this at your request. The second ER that you went to correctly repeated these tests, as you were getting worse, and results that were normal at the urgent care clinic may have turned abnormal in the interim. I see no problem there. And yes, you still owe them money for services rendered. The nature of medical care does not allow money-back guarantees. Nothing is broken.
You are not correct in your statement that private hospitals can refuse care to the uninsured. Federal law mandates that any hospital emergency room, whether public or private, is required to render emergent and urgent care without regard to ability to pay, to anyone who presents to their emergency facility. There are strictly enforced rules which impose five figure fines on institutions and on-call physicians who do not provide this care in a timely fashion. This policy does not apply once it is determined that there is no urgent problem; however anyone in significant pain would qualify for this care. The hospitals and physicians are prohibited from making any type of financial demand on the patient as a condition of providing this urgently required care. Hospitals can and do decline to provide nonurgent services for financial reasons, but not in the emergency room. Statements made on medical TV dramas that you cite as your source of information are not necessarily accurate.
Yes, once I have received whenever payment I get from the insurance company, I do need to get the rest from the patient. Again, there is a legal reason for this, as well as a financial one. The financial one is easiest to explain. You may be a socialist, believing that anyone who has a higher income than you owes you a contribution, but I do need that money to pay my office staff, rent, utilities, insurance, and then take care of my family. The overhead for a medical office runs between $500 and $1500 per day, depending on specialty, so I have to take out a gallbladder every day just to pay the overhead before I start making a dime. The legal reason why I need to get the rest of the money from you is a little more complex. Most insurance plans, with whom physicians sign legally binding contracts, state that the insurance plan will pay a given amount, usually 80%, of the agreed upon total allowed. The doctor is required to bill the patient for the other 20%. If the 20% is not billed, it means that the actual amount charged by the doctor is the 80% amount, and the insurance company then has been defrauded, because it is responsible only for 80% of the total amount. For example, if the fee for an office consultation is $100, the insurance company pays $80 and the patient pays $20. If the doc does not demand $20 from the patient, the fee then becomes $80, and the insurance company would then only be obligated to pay $64. This is especially problematic with Medicare, where doctors who out of the kindness of their hearts have blown off the 20% co-pays, and have been charged by the government for fraud.
Tough luck about the need for open surgery. Five to 10% go that way, but those cases are unsafe if the surgeon persists in trying to get the gallbladder out through the scope when it is clearly unwise.
Graham-
I’m not going to try to convince you that our system is better than Canada’s, only a Canadian who dies while on the waiting list for a coronary bypass could do that, or somebody who hobbles around on sore knees for three years waiting for his knee replacement. Not even the hordes of Canadians who head south to have their elective procedures done in Buffalo or Minneapolis would convince you. In Canada, Mr. Moore could have been fed a diet of antibiotics, anti-emetics, and pain pills, and sent home to live with his pain and nausea until his time for surgery came up. Since Mr. Moore’s primary complaint was of the expense that he had to pay, and not of the quality of care, it is only right to point out that the expense of living in Canada is higher, as their income taxes are substantially higher than ours. Indirectly, he would be paying a whole lot more for service that at best would be equal to ours, and in my scenario much worse.
The point that I was trying to make, unsuccessfully, is that while our medical care system is quite expensive, the customers are getting an awful lot for their money. Mr. Moore’s experience was atypical in that he ended up getting traditional surgery, but my point stands and that he received care that was within his ability to pay, that Queen Victoria could not have received. No, I do not like a lot of things about our current system. Too much is lost to administrative costs, and we could do a much better job of taking care of poor folks. In the old days, charity hospitals and clinics could do that, but the legal and government demands for anyone who provides any type of medical care prevent that today. As has been pointed out by many of my colleagues in the vast right-wing conspiracy, everybody unhappy with the current political situation threatens to go to Canada, but nobody does it. But the Canadians do come here for their medical care. How about that?
JB, how much do you spend to maintain an office staff that deals with all the paperwork of all your patients’ insurance companies, keeping track of the requirements of each company and each plan, getting authorizations from each company’s clerks, tracking down billing problems, and otherwise negotiating multiple bureaucratic mazes?
For all the good you describe, it’s all the duplicative private bureaucracies that consume tremendous amounts of healthcare dollars without helping a single patient. Each company has to maintain a staff of clerks to administer the provisions of all the plans (and haggle with the staff of clerks every provider has to maintain for that purpose). They also need a staff of underwriters to screen out undesirable candidates for their precious coverage, as well as a marketing department. They have to pay taxes. They have to pay their Executive Team the lavish compensation packages to which they are entitled by Divine Right. And, most importantly, they have to produce spectacular profits each quarter to delight Wall Street analysts and make their stock irresistible to investors. None of these expenditures do anything to deliver health care to patients, but they do make a relative handful of executives and investment bankers filthy rich, the envy of every country club they belong to. And– I forgot to mention– they need to spend constantly increasing amounts on lobbying and campaign donations to fend off Evil Liberals who think it might be better to spend the money on providing care rather than on the new yachts the HMO Executives deserve every year by Divine Entitlement.
The most recent data I’ve seen say that private insurance companies spend 12% on administrative overhead (which presumably includes new yachts and jets for the Executive Teams), while Medicare (our equivalent of Evil Canadian Single-Payer Socialism) spends between 1% and 3% on overhead. That doesn’t sound like the best use of health care resources, despite what the lobbyists want us to believe.
I have trouble believing that a single bureaucracy, particularly one that doesn’t have to spend money on marketing, underwriting, taxes, mergers, “unlocking shareholder value,” and mansions for executives, would not be better than the metastasizing mess we now have. I also can’t believe that corporate executives will be so committed to ideological solidarity with their colleagues in health care that they’ll prefer to give a constantly-increasing share of their bottom line to pay for the current system and its parasitic expenses.
JB,
I don’t know why you continue to throw around socialist, assuming that anyone that thinks this health care system is a disaster is a socialist. If yours is a binary view of reality (socialist or not), it’s just not that simple.
I don’t think anyone here is arguing that health care shouldn’t cost money, and that health care doesn’t cost a *lot* of money. I’m saying that it does cost a lot of money, especially in the United States, but that by spending TWICE AS MUCH as other countries, we’re not getting TWICE our value–nowhere near it. Ted had the same point I did: how much of your office overhead exists because of duplication of forms, time spent on hold with HMOs, etc, all because of our fragmented system? How much could be saved if all the hospitals were *sharing* data, so LM didn’t have to get so many of his tests duplicated?
I’d really like to see your numbers saying that “hordes” of Canadians come to the US for medical care. The data I’ve seen refutes that point over and over, yet the myth continues to live on.
I just want to say that despite my still leaning more toward agreeing with Graham than with JB, that I learned a few new things from JB. So, thanks, JB. We can all always learn from any side of a discussion.
- LM
A few final comments and then I’ll cease. This dispute will be resolved on this blog, obviously.
There are 2 reasons why I use the term “socialist.” The first is that it is shorthand for a system in which person A decides he needs or wants something, and persons B and C have the power to compel person D to pay for it, or, in the vernacular, a socialist is “someone who would give you the shirt off my back.”
A second reason that I use the term socialist is that the arguments of Ted and Graham are superficially appealing, and straight out of the playbook of Marx, Engels, and their followers. Well-intentioned, intuitively sensible, and never put into action in any way that would be remotely acceptable to most Americans. Railing against the inefficiencies of the free market system is not original here, and not a successful argument with anyone with real world exsperience. The reason that Medicare is so “efficient’ (low admin cost) is that it offloads most of the bureaucratic work onto the doctors- that’s why our costs are high and their costs are low. Costs are not eliminated, just shifted.
Many agree that hospitals sharing data would lower costs (I already explained why the 2nd hospital appropriately repeated LM’s tests). I agree that it would lower costs, after the massive infrastructure is put into place. You then have a system where anyone with computer skills will be able to find out about your abortion, HIV status, or blood pressure medication compliance. At least, that’s what the ACLU and the privacy mavens are worried about.
The current system is far from perfect, but despite current fears, Americans do not die in the streets for lack of health care. We have a dynamic economy that is the envy of the world, and I can’t believe that it will be in our nation’s best interest to put an additional 15% of the ecenomy under total government control.
According to the Institute of Medicine, there are 18,000 unnecessary deaths each year due to lack of health insurance. They’re not dying in the streets; they’re dying in hospitals, and presented too late.