US Medical question

You are referring to Kaiser shipyards of course. Building mostly liberty ships I believe (lots and lots of them)

EvanR wrote: Since employers couldn't offer higher wages to lure workers away from their existing jobs, they began offering benefits, including employer-paid health insurance. That's how we got out de facto system that still operates today.

What's frustrating is that much of the working populace assumes that this is the way it is because it's the best way. Like it was planned that way by our capitalist forefathers who decided "employer paid health benefits are the best way of having a healthy society." Like George Washington himself offered his slaves a PPO.

No, we just ended up with this system by circumstance, and the best country in the world, with the hardest working populace and the most brilliant minds can't figure out a better way.

STM317 wrote:

jj wrote: Why isn't medical service like other industries where companies compete to have the lowest price, and therefor win more customers??

Because in other industries, you can choose to buy nothing with very little side effect. If you get fed up shopping for a cell phone, you can go without it. That's not a realistic option in most cases with medical care. If you break your arm, you can't really choose to forego treatment. If you have chronic pain issues, you're likely to seek treatment at almost any cost. If you have a life threatening illness, you're going to do whatever it takes to fight to remain alive. Therefore, the medical industry is not a true example of a free market. They have people against a wall and everybody knows who has all of the leverage. I know that I've said it before, but the most logical example that I can come up with to emulate to reform the medical industry would be the utility sector. A long time ago, people decided that utilities were critical to our way of life, and everyone should have reasonable access to them. They're considered a basic need, and are regulated to ensure that they are priced fairly so that the consumer can't be bent over a barrel. Of course actually implementing changes like that would require a massive number of people to willingly cut off their own access to the gravy train and that seems unlikely.

Competing for the lowest price in healthcare would give you the crappiest healthcare that could possibly be done for that dollar amount. Which would be little to nothing. There's a reason why I don't accept Medicaid and its because it literally pays me less than it costs me to turn my light switch on.

I do alright, but I'm not on "the gravy train" by any stretch of imagination. If you want Doc's to take a pay cut, then the schooling better be free and there better be other benefits. Otherwise why is someone going to dedicate 10-15 years of their life, after college to go into the trade?

Sorry, altruism only goes so far....

In reply to docwyte:

You're kind of proving my last point for me. It's never going to happen. But for the sake of discussion, Doctors in other countries do just fine for themselves don't they? And their medical costs are far lower per capita, so what's up with that?

Say for the sake of discussion, that it does happen one day, and the medical field looks more like the utility industry. There are plenty of people in the utility industry that do very well for themselves. And they do it without raking consumers over hot coals because there is regulation in place to avoid price gouging. Heck, why are there regulations in place to avoid price gouging on a $5 gallon of gas, but not a $5,000 medical procedure?

I'm not accusing everyone in the medical industry of being evil, or even having any control of costs in any individual way. I'm typically a small government type, but I think some regulation of medical costs to protect the consumer could benefit nearly everyone. If this trend continues, people will eventually choose to forego medical care due to high costs, or they'll go to places where the care is similar but the prices are significantly lower. It's already begun, but it will only grow as costs soar.

It sounds like having price controls on medications would be a helluva start.

Like that would ever happen.

Doctors are trained to not care about how much something costs. Which may be for the best, insofar as the role they have to play. But when "you need a million dollars a year in medication to live" gets a question of "Who is going to pay for that?" and the answer is "¯_(ツ)_/¯, insurance, government, not my problem"... What do you do?

I don't have answers, I won't pretend to, but I think a lot of people are asking the wrong questions.

I have no idea if doctors do well in other countries. I suspect in the 1st world countries they do, but they also can opt out of the socialized medicine programs there, which is probably a large part of them doing well.

In 3rd world countries they do better than the populace, but I wouldn't say they do well. Procedures down there are so much cheaper because property is cheaper, labor is cheaper, even the price of supplies are cheaper.

Totally different market compared to here. My payroll, supplies, utilities etc FAR exceed any 3rd world country. Hence my fees are what they are.....

In reply to docwyte:

Precisely. I'm not suggesting that Doctors alone are responsible for high costs. It's a systemic problem. Anything that is related to medicine seems to be deemed so critical that cost is no longer a consideration.

I've told this story before, but when my father was in hospice, he lived with us. At some point, his hospice nurse ordered a common, over the counter medication, but it was going to take a couple of days to arrive. So, in order to get him the medication sooner, I went to the corner drug store and bought some for under $8.

A couple of days later, the medication that had been ordered arrived, and with it was an invoice. The exact same brand and size of medication that I'd purchased for under $8 was invoiced for around $180. If the corner drug store can make a profit selling it for less than $8, then it seems a bit much to be billing people for more than 20 times that amount just because it's part of "end of life" care. That's taking advantage of people at their most vulnerable and shouldn't be tolerated.

It's not just hospice costs either. WilD linked to a great article a couple of pages ago that everyone should read. It gave several examples of how outrageous medical costs and billing have gotten, but the one that stands out was an echocardiogram. The price for what is a pretty routine procedure varied wildly between various locations in the US, but was always at least $1000. The same procedure in Japan is under $100. Same basic level of care, similar energy and real estate costs, etc.

In reply to docwyte:

I understand drug prices are cost-controlled in many countries. I sometimes wonder if we in the US aren't by default subsidizing some/most of that.

In reply to Ian F:

I work in an area with heavy pharma and medical insurance company presence. According to glassdooor, employees at this firm with my level of experience and responsibility make $100-150k more per year than I. wish I had an in over there.

STM317 wrote: It's not just hospice costs either. WilD linked to a great article a couple of pages ago that everyone should read. It gave several examples of how outrageous medical costs and billing have gotten, but the one that stands out was an echocardiogram. The price for what is a pretty routine procedure varied wildly between various locations in the US, but was always at least $1000. The same procedure in Japan is under $100. Same basic level of care, similar energy and real estate costs, etc.

Huh. i had a series of those test when I was preadolescent and I know that there's no way my mom could have afforded $1000/pop (adjusted backwards for inflation).

Access to insurance enables higher costs.

Rinse, repeat.

In reply to docwyte:

Realistically, how much would it reduce the costs of healthcare if:

Medical schools were publicly funded so you didn't have the debt load starting out...
Bureaucracy was streamlined so that you did not have to devote as much labor to paperwork...
There was less threat of malpractice lawsuits (presumably reducing the need for running CYA tests, and cost of insurance)?

Obviously those things increase the cost, but is it like "I dunno, 10-20%", or like "That's half of the overhead I have to deal with."

pheller wrote: the best country in the world, with the hardest working populace and the most brilliant minds can't figure out a better way.

Yes we have!

School debt is a big deal now. Not unusual for people to have $500k or more.

The big problem is something that just can't be addressed by streamlining bureaucracy. That's the cost of living here in the US. My largest expense is payroll and rent. Those salaries are driven by the cost of living. I can't pay someone $5/hour here for a $40/hour position the way I could in Costa Rica (or something).

Plus I know my supplies (the same ones!) are far more expensive here than over seas, that would help, but my supply bill is really only 5-6% of my costs....

In reply to docwyte:

My PCP recently quit to start a concierge practice. She told me that every person I had seen on my way into the examination room was there because of the need to deal with the insurance companies. Her new practice was two doctors, a pharmacist and a receptionist. How much of your staff do you think might disappear if you could just send in a bill to a central payer ?

In reply to Zomby Woof:

Well played, Sir, well played.

DeadSkunk wrote: In reply to docwyte: My PCP recently quit to start a concierge practice. She told me that every person I had seen on my way into the examination room was there because of the need to deal with the insurance companies. Her new practice was two doctors, a pharmacist and a receptionist. How much of your staff do you think might disappear if you could just send in a bill to a central payer ?

But that can't work until we have a way of reining pricing in. As pointed out, when purchase is a foregone conclusion, there's no incentive to not charge whatever you feel like it. $180 for an $8 pill, times everything, needs to be stopped. Period.

In reply to Knurled:

I don't disagree with your statement. Office visits are just one element of a complex system. A visit to my current PCP is billed out at $196. My old PCP would see me in her concierge practice for a monthly fee of $70. That's for as many visits as I need .She was also saying that the in-house pharmacy would sell drugs at pennies on the dollar. A lot of the current costs have to be caused by the staffing needed to deal with multiple insurance companies, Medicare, and people paying their own way. I go to the doctor twice a year just so he'll renew my prescriptions and they're prescriptions that he says I'll be taking forever, so why do I need to show up and ask for a new scrip? It's waste and my insurance company pays for it and simply gets it back in excessive premiums. That's just one example to support your point.
The insurance companies will negotiate pricing with health care providers and pharma companies, that goes away in a single payer system and pricing becomes a dictated rate.But, if that dictated rate isn't high enough to make a living for the medical personnel they walk away from the profession. I've lived with both systems. I'm Canadian and lived there until I was 47 years old. The last 17 years I've lived in Michigan. Neither system is perfect. The trick is finding a way to combine the best elements of both.

Keep writing and deleting - bottom line - the US consumer is getting a crappy value proposition when it comes to healthcare services. Intended fixes are making the value proposition worse, not better and personally I have little faith it will improve until it gets a fair bit worse. Going to go do car stuff.

docwyte wrote: The big problem is something that just can't be addressed by streamlining bureaucracy. That's the cost of living here in the US. My largest expense is payroll and rent. Those salaries are driven by the cost of living. I can't pay someone $5/hour here for a $40/hour position the way I could in Costa Rica (or something). Plus I know my supplies (the same ones!) are far more expensive here than over seas, that would help, but my supply bill is really only 5-6% of my costs....

I don't want to dismiss your opinion since you have an insider's perspective that many of us will never gain, but the cost of living between the US and Canada, or Europe, or Japan isn't very different, and in many cases it's higher in other countries than it is here. Yet we spend quite a bit more on healthcare per capita than those other countries for what is essentially the same level of care so I find it hard to believe that would severely impact our costs in a negative way.

There's no single root cause of this. Costs across the board have outpaced inflation in a way that defies basic economic assumptions. Typically, as tech ages and becomes more mature, it gets cheaper. An MRI has been basically the same for the last couple of decades and should be getting cheaper in relation to inflation, but they're getting more expensive. Most medication Follows the same trend. Hospital stays too. Malpractice insurance is up for doctors, and overall health insurance is up for pretty much everybody.

I'm a unique case in that I'm retired frim the military. I have health care coverage options in and out of the VA system. The VA's struggles are very public, so I won't repeat them here.

I pay a small monthly amount (~$60) for TriCare Prime. It covers myself and my wife and two kids for all medical and prescription medications. We see private doctors and go to regular hospitals, clinics, etc. It's $12 for most copays. We have the option to add on dental and vision for additional monthly cost (right now we use my wife's benefits through work for that).

TriCare forces the providers to write off a significant portion of their bill (up to 65% I've seen), which controls costs. If we as a country move to universal health care, I would like to see it run like TriCare where the payer is setting the price.

docwyte wrote: School debt is a big deal now. Not unusual for people to have $500k or more. The big problem is something that just can't be addressed by streamlining bureaucracy. That's the cost of living here in the US. My largest expense is payroll and rent. Those salaries are driven by the cost of living. I can't pay someone $5/hour here for a $40/hour position the way I could in Costa Rica (or something).

While I agree that cost of living does play an important factor, I think the school loans really are the big elephant in the room that's really talked about that much. And that is (or used to be, if you talk about, say, Britain) one of the main differentiators.

I've got experience with both the UK and German system. In the UK, it's obviously a big monolithic system with some additional privatised care on the fringes. The private care part is expensive, the NHS itself is free at the point of delivery but paid for with relatively small amounts of taxes. Now the taxes would need to be a bit higher to sustain the cost increases (and catch up on deferred maintenance etc), but the structure of the system also cuts down on the cost doctors have to incur to have an NHS practise. Simple example, X-rays and MRIs usually get done at the local hospital, so the practises don't have to pay for the machinery and upkeep, and the ones at the hospital have essentially 100% utilization. That said, the downside of this "socialised medicine" is that sometimes there are wait times with specialist referrals - when my family doctor suspected I might have some growth that may or may not be worrying, it took 3-4 weeks to get the appointments to get ultrasounds done, followed by MRIs. And yes, you can get extra insurance and get these done at private practises, often faster.

The German system is somewhat different, it's closer to the US in the sense that while everybody is required by law to have health insurance, there are competing (although they seemed to spell "competing" in a funny way, more like "colluding") for profit and non-profit health insurers. There isn't much in the way of subsidies other than employers usually picking up 40-50% of one's health insurance premium. While health care is generally somewhat easier to access than it is in the US and the overall cost is lower, the cost has been creeping up and benefits have been going down at the same time. That said, the cost isn't as high as it is in the US but staffing levels are higher than in the UK (suddenly you have to have billing specialists that do nothing but deal with insurance companies day in, day out) and on the face of it, deliver more or less the same care.

However, in neither of the countries does a doctor start out $300k-$500k in the hole and an RN with something like $50k-$100k in student loans.

I found this thread to be rather interesting. The provision of health care seems to drive some deep moral choices for some and simple analysis from others. I am happy that for the most part this thread has been civil in presenting everyone's experience rather than just pushing opinion.

Thanks GRM Forums people, where ever you are!

So to the OP I think the US system is that complicated that someone would end up in a situation where they need to go to internet begging to get an operation.

Some things I learned along my life:

• Health insurance is worth it. When something really serious happens six (6) figure total charges can accrue quickly. I do the math and my annual premium for the max coverage and minimum copay/deductible limits is a tiny fraction of the impact of recovering from a car crash or heart issues etc.
• States management of federal medical funds is a terrible idea. Having dealt with three different states for medicaid/medicare I came to learn how some states are using the funding as slush funds basically. They can move it between several different pots instead of using them to pay for a young adult's heart surgery for example. So weird as it is, if the person noted in the original post moved to the right state with the Affordable Care Act still in place, the surgery might be very low to no cost to them.
• Prescription medicine is a complex world when it comes to costs. Very complex and a whole other animal from the crazy health care maze. I have been fully covered by my insurance for some unique meds and then when getting something not so unique copay is $190. Why? No one knew, even the insurance customer service said it was "interesting" and escalated it to see if it was a code error. It wasn't.
• I watched my Uncle fight cancer in Canada, the USA, and then back in Canada. Both have their issues in getting him what he needed but he definitely found it easier in Canada. Mostly because they wanted to help him get services while in the USA there seemed to be a need for him to remember to ask for each little thing. Not easy to do on Chemo.

It isn't easy to talk about healthcare without the politics. So I will stop typing now

Ok started typing again....sorry

So most of my career I have ended up doing some root cause and systems analysis of large systems.

• Large system change takes commitment to the time needed to finish the change. The #1 failure of most mergers/corporate culture changes/sourcing strategy changes is that the leadership don't want to wait the time they knew they needed to wait to get to the benefits. The ACA is in this mode. The realization of the benefits would probably hit between year 7-8 from full activation. This isn't too long for any large system change.
• To respond to a post about a school district changing their healthcare to something more expensive and restrictive. Businesses and even state/local entities were expected to only look at cost and instead of smartly choosing to pay more to get more or pay the same to get a little bit more, they would chose to pay less to get less. Essentially it was going to allow some folks to use the ACA as a scape goat to lower their overhead and put the blame elsewhere. My friend's father is going through this now. Eventually he realized his company's owner is choosing to maintain his income level and his personal healthcare and cut his staff's which is his choice not the fault of ACA. The only solution is the oldest solution. Migration of workers would eventually normalize things. If the best teachers left after the benefits change the school district would probably "reevaluate" their options. After the initial story from my friend's dad, my first question was, where has he applied to so far?
• The ACA has many flaws and any new system will. The goal of any change management it to do just that, manage the change not pull the trigger then do nothing. Humans will do lots of stupid stuff like removing a li-ion battery from a sealed product and carrying it in their pocket with loose change and keys. Boom. So as you push out a new healthcare system you need to track it but resist any update for not critical things as in, "oops we didn't include cancer in the list of covered ailments." Otherwise wait until you can learn if the issue will self resolve or needs action. That cost time and money and that is where most leadership choke. Also the politics of knowing about a problem and not knee jerk fixing it is a real bummer. For some reason politicians get more support for doing anything than they do for doing the right thing.
• The cost of healthcare is going up and for many reasons. The cost of education is ballooning but that is somewhat justified due to the increased cost to the university to run the program and keep/recruit good instructors. For instance think about this; between 1950 and 1990 the need to revamp the medical program facilities was rather light. Adding new scanning technology was the biggest expense. Now since 1990 to now you have not only the standard computer infrastructure to replace and increase year over year you also have an explosion of need of very very high end labs to support the medical school. Teaching DNA based cancer medicine development? Yeah you need a new teacher but you also need all the techs, lab space, and new teachers and support for teaching new techs on how to complete the job. So an interning Dr may request the thing with the same Dr's order form but the cost to complete it is very different between "apply cast to broken arm" and "prepare 5 week DNA based medical plan with additional DNA and stem cell growing of new liver for transplant." Medical schools need to buy that capability so they have to get paid for that.
• Then as my Mexico colleague said, "We are patient, just let your schools figure it out then launch it here for tenth of the price." He had to admit that the biggest difference was in Mexico getting a bad reputation is more dangerous than being sued by your patients. So his Doctors don't carry much insurance.

Javelin, I have TriCare too. When I see the write offs providers are forced to take, I'm constantly surprised that there are providers willing to take it.

They don't have to. That's going to become an issue at some point, we'll have this great insurance and nobody will accept it, or the ones that do won't be have an open appointment for months and months. Same as medicaid. So having the insurance companies (who are for profit, very much so) set the reimbursement rates for a universal health care system will drive people away from becoming doctors entirely.

STM317, yes, all those other countries have a universal healthcare system and their cost of living is very similar to ours. Well, not really because their tax structures are significantly more than ours, cost of goods is significantly more than ours. Price of cars for instance in Northern Europe for instance.

Yeah, health care is cheap there, but that's because they're paying for it already in taxes and other ways.

No free lunch here....