A Model for Health Care That Pays for Quality - page 2

seeing low fees for family doctors as a weak link in the nation's health care system, some big employers and health insurers are seeking new ways to pay doctors to reward high-quality medical care.... Read More

  1. by   lamazeteacher
    Well, in the interest of fairness, I think all healthcare providers: Nurses, phlebotomists, X-ray techs, porters, etc. should be included for this to fly. Or maybe those I mention have already realized that the greatest reward is in knowing ourselves, that we performed to the best of our abilities.
    Now for my angry response! The audacity of physicians! How typical to stamp their big feet and say I'll only be good if I'm paid more. That a presumably august board thinks this notion is presentable to anyone, makes it a sad day.
    My Obstetrician (who at that time, 1972, made $800,000/year, said his divorcing wife who managed his office) spent lots of time with me, complaining about the cost of his malpractise insurance! In the prenatal classes I taught, I've always instructed participants to say, "It's hard to ask my questions when your hand is on the door knob, doctor". The standard of time spent is ridiculous, if the patient understood not one word said. Should we pay a surgeon more, if he/she throws only 2 instruments on the floor in pique, rather than the usual 10? Or should higher pay be given the surgeon who plays the patients' preference in music during the surgery, rather than his/her own? My tongue is cleft to the side of my cheek!
    When healthcare costs are hitting an all time impossibility, talking about more money for doctors who already have substantial incomes, seems more than ridiculous - try greedy. How about allowing payment for utilization of more Nurse Practitioners (no I'm not one), or less high cost medications, or less co-pay? Watch, the increase in a doctor's fee will probably result in higher co-pays, so the patient knows they're getting "the best". I could go on, and on.
  2. by   cmo421
    Quote from ZASHAGALKA
    Oh come now. Look up neomercantilism. The insurance companies/big business is in the pocket of gov't. They are one and the same.

    Until gov't stops sleeping with the power players in order to work against you, there is no practical difference between the two. Your favorite cartoon mocking those against gov't restricted healthcare by inferring that big insurance IS already restricted healthcare; that's a joke. The joke's on you (or rather, all of us). Big Insurance, Inc., can only act the way it does BECAUSE it has gov't protection that ensures that YOU aren't its ultimate customer. That protection is the third party payor financing scheme created by gov't tax breaks that IS the problem with healthcare. It's collusion, in the name of power, er, I mean, 'benevolent dicta... er paternalism'.

    I don't need any of their versions of 'benevolent paternalism'. Like my doctor needs any more interference in how he provides me care. Step back!

    Don't tread on me (or my doc).



    Due to my very recent experience I would have to agree with u here . Also many doc's are in the pockets of insurance companies also. Look at the recent going on in Rhode Island. FBI involved in the scam between politicians and a major insurance company. Also involved is a very large,well known drug store chain.
  3. by   dria
    Quote from hm2viking
    the other problem is that from a behavioral standpoint patients are notoriously bad at choosing which health care needs to be priority funded (ex htn meds) and heath care needs that can wait. some benevolent paternalism is needed to help patients make good choices.
    ummmmm...no....nonononono....ab-sou-lute-ly not!!!!
    (rant over)
    "benevolent paternalism" no thank you. i would prefer educating individuals to become better health care consumers. if they can research the latest and greatest in regards to cars, they can do it for health care.
  4. by   dria
    Quote from zashagalka
    i understand what you are saying, and healthcare is an exception because it is based largely on location, location, location.

    however, quality is still an issue that improves with the free market. it's not about any individual practitioner so much as it is about the process. competition ensures that the best innovations are adopted, at the best prices.

    if a new technique is developed that saves more lives or provides the same quality of care for less money, that technique is going to be either copied, or improved upon. so, 100 doctors, or even 10, competing to provide care, will adopt and improve upon the fabric of healthcare for the community.

    it really isn't about doctors, however. most doctors have all the patients they want, and so, the level of competition there is artificially controlled by controlling the number of new docs that can go to med school. so, you are going to have bad doctors that survive in business just because there are enough patients to go around.
    ummmm....sure...because there is not one single foreign trained md practicing in the us. but i agree in that there is value in competition between docs based on quality outcomes, and efficency of care.

    this is a built in mechanism. a true libertarian will tell you that the solution is to get the gov't out of the business of licensing doctors. that would allow true quality to rise to the top. once again, gov't interference in the free market. that's another debate, however.

    the true innovations are going to be in costs. a doctor simply can't charge 200 bucks a visit if you are paying directly for it. the beauty of the free market is that such a beast can only charge what the market will bear. the downfall of our current third party payor system (created by gov't interference in healthcare) and single payor care (more gov't interference in healthcare) is that you don't pay directly for care, and so, there is no rational check on how much it costs.

    very true....persons who share in their costs of healthcare use services more responsibly....however, such a proposal would likely cause an uproar among consumers. there is a pervading sense of entitlement regarding healthcare...but once again, i digress.

    if you get the gov't out of pricing of healthcare, then healthcare could only charge what the market can afford to pay. no way ct scans cost 700 bucks each that way.

    in fact, some docs are going to cash only business and their visits cost around 50 bucks, cash up front. ultimately cheaper on the doc in avoiding insurance run arounds and cheaper for patients that aren't hung up on insurance co-pays.

    yeah, now they will be hung up on their out of pocket cost...

    the cost of healthcare, if we got the gov't out of financing it completely (that means ending employer based tax breaks to provide you with your insurance) would spiral downward, making it much more affordable for many of those that can't afford care now.

    at that point, the gov't can pick up the tab for the gappers. the result would be universal coverage under a condition of prime quality/cost performance. the free market is the best financing mechanism yet developed - even for healthcare.

    it's time to get the gov't out of the job of financing your healthcare. frankly, they've made a complete mess of it, and that is why we have the problems with healthcare that we do, today.

    help me to understand exactly what you are proposing here: i get that you are in favor of eliminating coverage for things like routine office visits. who will pay for the big stuff...like surgeries, nicu stays etc.? private insurance? the government? the tooth fairy?
  5. by   ZASHAGALKA
    Quote from dria
    help me to understand exactly what you are proposing here: i get that you are in favor of eliminating coverage for things like routine office visits. who will pay for the big stuff...like surgeries, nicu stays etc.? private insurance? the government? the tooth fairy?
    1. catastrophic health insurance would be much cheaper than pre-paid health care, which is what we call today's version of health 'insurance'.

    for example, how much more expensive would your car insurance be if it covered: gas, oil changes, paint jobs and non-accident repairs? maybe alot more expensive? of course.

    return to actual insurance for healthcare - kicks in upon admission to hospital, or at a high yearly deductible.

    for this insurance, i'd be in favor of 'community rating' so that chronically ill can get in the game.

    2. end all gov't tax breaks for employer-sponsored insurance. the key to insurance portability is to get your employer out of the process. your car insurance isn't linked to employment. why on earth should health insurance be? the only causal link between the two is that the gov't decided to put its hands on the scale and the result is that you needed to have a partner so that you could afford it after gov't interference made it unaccessible for most.

    3. healthcare savings accounts (hsas) to pay for out-of-pocket expenses. the cost of a good hsa plus truly catastrophic insurance would not be more than just insurance alone is now. the difference: you've transferred the cost of your routine care from third-party payor to first-party payor. the result is that you now have control of your care. the result is that providers must now charge what you are willing pay.

    the result is that healthcare pricing will be suddenly re-aligned with the real world of prices. there could be no 700 dollar ct scans if you had to pay for it. there would be ct scans, though. they'd just be priced at what the free market would bear.

    4. after the market causes a severe price correction in healthcare, then, and only then, the gov't could contract out a combined insurance and hsa plan for those in the gap. since more people could afford the real price of healthcare instead of the current inflated gov't model, that would be fewer people to cover.

    5. get rid of medicare. the elderly that truly need help should be covered by #4, above. dealing with that runaway entitlement by bringing price consciousness to healthcare and by means testing all gov't healthcare aid will do wonders for shoring up our economy and maybe, freeing up some money for ss.

    besides, it's just 'not fair' to pay for some rich person's healthcare. medicare is going to die anyway; it's already on life support. better to address it now. alan greenspan, in his latest book, admitted that the sooner runaway entitlement programs die from morbid obesity, the sooner we can devise more rational alternatives. this idea, above, is a more rational alternative.


    now, you have a model for quality healthcare. it puts choice in the hands of consumers, it gets the gov't out of financing healthcare and only gives them the minor role of subcontracting out care for the gap. now, you have universal coverage. now, gov't is out of the routine aspects of your care, and, so is your employer.

    most important, now what 'insurance' that remains is marketed to you like geico and allstate - aggressively taking into account your approval and satisfaction instead of only your employer's and the gov't.

    a win-win for everybody not vested in a gov't monopoly for political reasons.

    the market works, and works well. even for heathcare. it doesn't work now because it isn't a free market model now: it's a primarily third party financing scheme created by gov't. the politicians answer to that? total gov't financing. amazing isn't it? they screwed it up this badly now and the only solution we can find is more faith in gov't? wow.

    there is an alternative to the current system and the proposed gov't monopoly. it is a system that has been tested and well-proven, for centuries. it is the free market.

    Last edit by ZASHAGALKA on Nov 8, '07
  6. by   dria
    thank you...im sure it took you quite a time produce that reply...sounds good to me. i absolutely agree that we would be better served by going back to the indemnity policies of the earlier days that paid catastrophic costs only. think the hmos of days past are largely to blame for that sense of entitlement.
    do you also support continued tax breaks for these hsas? and what to do with the dismally low participation rates (around 12% for cdhps, the closest thing to what you are proposing)? americans, it seems, are willing to spend their money on anything but healthcare. in all honestly, from what i've seen, the current cdhps sometimes force people to forgo necessay care....but i believe that your thought is that will be remedied by the price correction...(im thinking out loud here)
  7. by   lamazeteacher
    Here's Granny..........
    I love how you think medical plans past worked. Catastrophic insurance plans were in addition to the regular ones, and had a huge deductable.
    Most planners for future healthcare plans are going in the direction of making Medicare a model for all aged people (like no coverage for prescriptions). Plan D of Medicare is a monumental faux pas! Now that "elderly" folks (I like to think of myself as "senior") who subscribed to that plan have found, they pay more in monthly payments to multiple programs (for each company manufacturing their meds), and deductables, than their medicine would cost at Costco. Other drug programs that are not through pharmaceutical companies, severley limit coverage to generics and less expensive drugs, as HMOs do. I remember asking an HMO "customer Service" person why she wanted me to pay again for drugs that I'd tried in the past for GERD, and found ineffective. I said, "Why does your company want me to be in pain?" She had no answer and no coverage, so I've wound up begging physicians for their samples of Prevacid (which is demeaning, but Prevacid sells for $9./capsule), which works (but since it's a prescribed drug, insurance companies would be responsible for its payment - and they don't want that, which is why their formularies don't include it)! I know similar situations prevent patients from having other, needed medications.
    Participants in this thread, have ideas for programs other than one similar to Canada's. Why is that?
  8. by   HM2VikingRN
    from paul krugman:
    rudy giuliani’s fake numbers on prostate cancer — which, by the way, he still refuses to admit were wrong — were the latest entry in a long, dishonorable tradition of peddling scare stories about the evils of “government run” health care.
    the reality is that the best foreign health care systems, especially those of france and germany, do as well or better than the u.s. system on every dimension, while costing far less money.

    source: http://www.nytimes.com/2007/11/09/op...on&oref=slogin accessed today.

    we can and must do better in the allocation of health care dollars. one of the things that this article is alluding to at least indirectly is the idea of establishing medical homes to coordinate care. the evidence is there to show that patients with good relationships with primary care doctors use health resources better and more wisely. increasing patient use of primary care providers is a cost effective way to reduce health care costs. (this is borne out by the health stats posted by a variety of countries.) it is much better to design a health care system that leads to better outcomes than spend time chasing ideologies.
  9. by   lamazeteacher
    As long as I can pick and change my primary healthcare provider at will, I'm OK with thet. However, making 2 doctors' visits when 1 would suffice, bugs me about double the time and money spent (e.g. ophthalmologist, orthopedist, cardiac specialist when known cardiac problems exist, oncologist, when cancer has been diagnosed, podiatrist, acupuncturist, chiropracter, etc., etc., etc.
    My aim is sufficient public information/education for the right choices to be made. And I know that system can be abused, but it won't be as expensive as seeing 2 doctors for 1 illness.
    Thank you so much, HM Viking, for keeping us in your well informed loop!
  10. by   lamazeteacher
    Can you imagine the political foreplay that type of program could produce? Please!!!!:angryfire
  11. by   dria
    okay granny....
    perhaps i had my dates wrong, but the concept was sound (perhaps we will need to hear from great granny....)
    health insurance did not exist in the early 20th century, as time passed, the following occured:
    as the demand for hospital care increased in the 1920s, a new payment innovation developed at the end of the decade that would revolutionize the market for health insurance. the precursor to blue cross was founded in 1929 by a group of dallas teachers who contracted with baylor university hospital to provide 21 days of hospitalization for a fixed $6.00 payment. the baylor plan developed as a way to ensure that people paid their bills. one official connected with the plan compared hospital bills to cosmetics, noting that the nation's cosmetic bill was actually more than the nation's hospital bill, but that "we spend a dollar or so at a time for cosmetics and do not notice the high cost. the ribbon counter clerk can pay 50, 75, or $1 a month, yet.... it would take about twenty years to set aside a large hospital bill" (the american foundation 1937, p. 1023). please note that there is no mention of payment for routine care such as office visits etc, only hospital stays....which, i think we will all agree...is certainly a catastrophic cost.
    a summation on the evolution of health insurance in the us:
  12. by   dria
    i remember asking an hmo "customer service" person why she wanted me to pay again for drugs that i'd tried in the past for gerd, and found ineffective. i said, "why does your company want me to be in pain?" she had no answer and no coverage, so i've wound up begging physicians for their samples of prevacid (which is demeaning, but prevacid sells for $9./capsule), which works (but since it's a prescribed drug, insurance companies would be responsible for its payment - and they don't want that, which is why their formularies don't include it)!quote]
    i couldn't have come up with a better example of this sense of entitlement that we have been discussing..."i paid my premium, now i want what i want, even though i know its not on the formulary, and therefore not a covered medication. i paid my premium...now give it to me!!!!!!
    it is impossible to provide unlimited coverage for any requested health services.

    why aren't we discussing canada's health system? because it isn't even working in canada:
    and, it too, has exclusions:
  13. by   lamazeteacher
    The referenced article neglected several issues that influence the rise in healthcare costs. The first that comes to mind, is the reluctance of doctors to provide their services gratis. Lawyers still do "pro bono" work for financially challenged clients; doctors don't take patients unless they like the payment their insurance provides (e.g. refusal of Medicare patients).
    When a previously well fixed patient falls on hard times through loss of employment or health, there is no hesitation by doctors to refer them to collection companies, now. I can't, for the life of me, understand why physicians, who do so well economically, are so uncharitable. After all free care could be a tax deduction called "lost income".
    It used to be, that in order to be on the staff of a hospital and have "admitting privileges", a doctor had to staff clinics regularly for the indigent and elderly. Now they want special compensation to draw blood from an umbilical cord for stem cell preservation, as they sit there in an uncomplicated delivery, waiting for completion of stage 3. They say if companies make money on stem cell storage, they want some of it!
    Until 1965, medical providers gave free care for Nurses, Doctors, and wives of Doctors. It was called "professional courtesy". Now there's no courtesy, just greed.
    My mother had her mastectomy at a New York hospital in 1942, where her brother-in-law was a physician. There was no charge for her 6 months spent in hospital, or the surgeon who, due to lack of antibiotics, pulled her through many surgical abscesses. My uncle was a "medical-legal specialist" in the employ of insurance companies, and examined candidates for coverage, going to their homes far away, in New Jersey, if necessary.
    I, at 3 years of age, went along for rides with him, spending interminable hours in his car, waiting as he visited his "patients". He told me that no neice of his would ever be allowed to become a Nurse (hence my vocation). He'd also testify in court if a lawsuit against a physician required that. His son became an orthopedic surgeon who was in the Korean "conflict" and headed the VA in Washington, D.C. afterward, now retired in Florida. I was incensed when I heard that recently a doctor took that post, and was said to be the first doctor to head the VA. How soon they forget......
    Rural doctors were paid in edible ways, and did better nutritionally during the depression, as did patients who raised their own food.
    Another change that raised healthcare costs, was disposable equipment. Yes, it's certainly more sanitary, which is cause for keeping it, but surely the costs of it are inflated. Nurses used to have little sterilizers in which glass syringes and reuseable needles were sterilized in boiling water on the units and in clinics, to use again. We sharpened the needles on a stone and occasionally had to skim muck out of the water. Infection rates were lower, then. Great Granny Nurses told us they even sterilized IV tubing, and bottles for IV fluids - and had no Nurses' Aides to do it for them. There were only R.N.s and orderlies who worked with patients in hospitals. We'd tell male patients, as we bathed them, that we'd wash as far as possible, and either they or an orderly would wash "possible". It was unseemly for a female to handle or see male patients' genitalia, then (in the late '50s).
    Now if we could just get doctors to wash their hands between patients......... Do you think they would, if they were rewarded with higher pay for it?