I'm excited to hear that CMS has begun testing the efficacy of value-based programs in select Medicare Advantage plans. The study of heart attack patients that increased utilization of free prescription medications and in turn lowered their overall costs to the insurer due to less hospital procedures...that's why so many are advocating Value-Based Care. It doesn't always save money, but it's proving to improve the quality of care and overall health of the patient, which is wonderful. An HCIM Strategic Adviser recently wrote a related blog on the topic of treating healthcare as an investment: https://www.hcim.com/health-care-should-be-treated-as-an-investment/
If we stopped paying our taxes because we cannot get affordable health insurance from a greedy market that an inept administration cannot comprehend sufficiently to counterbalance ... would that bring balance to the nation?
Dr. Fendrick is right - standard insurance is working against him and his patients.
And the answer is glaringly simple - Medicare for all, eliminating the "middle man" of the health insurance industry, and reigning in the price gouging of BigPharma with price controls. Shocking ideas, of course, but every other Westernized country seems to be managing it, at less cost and with better outcomes.
And the answer is glaringly simple - Medicare for all, eliminating the "middle man" of the health insurance industry, and reigning in the price gouging of BigPharma with price controls. Shocking ideas, of course, but every other Westernized country seems to be managing it, at less cost and with better outcomes.
6
The problem remains that providers, suppliers, pharmaceutical companies and healthcare corporations overcharge for their goods and services. They do this because Congress has tilted the so called marketplace in their favor, giving them near monopoly powers. Marketplaces only work if the walk away option is a real option. It almost never is with healthcare. Marketplaces only work if there is a balance of information between consumer and supplier that allows a fair evaluation of the options. No such information is available on most doctors and hospitals. Marketplaces only work if there is a balance of power between supplier and consumer. No such balance exists for healthcare consumers. They are at the mercy of providers when their health or even life is on the line. Marketplaces only work if costs and services are transparent before a transaction is made. Costs and even services provided are hidden from healthcare consumers. So stop it already with marketplace solutions. Either all Americans are worth caring for or some aren't in which case we are building an apartheid society. Oh wait, we already have that. This just makes the truth more glaringly visible.
5
This is a start but, we need to motivate patients to look at their lifestyle choices and see how those choices are impacting their health.
Yes, decrease the co payments when possible but the patient needs to assume responsibility for their part in their health and not expect they are entitled to have everything paid for.
The cost of insurance starts with the consumer.
Yes, decrease the co payments when possible but the patient needs to assume responsibility for their part in their health and not expect they are entitled to have everything paid for.
The cost of insurance starts with the consumer.
1
The reason value-based systems don't reduce costs is insurance churn. The average American changes jobs every 5 years and people without employer insurance or Medicare have higher rates of churn. That means any investment in someone's health needs to have a pay-off horizon under 5 years. If an intervention makes people 10% healthier, there could be a substantial long-term pay-off while the insurer paying for the intervention sees a loss.
The American healthcare system has plenty of incentives to reduce short-term costs and few incentives to focus on long-term outcomes.
The American healthcare system has plenty of incentives to reduce short-term costs and few incentives to focus on long-term outcomes.
9
The problem rests in the fact that the insurance companies -- none of which are truly non-profit and some like United Healthcare very much for profit -- are making the decisions. Unless the decisions rest solely with medical practioners -- unattached to any money making entity -- who are making the informed decisions with the best interest of the patient, needed care will not be provided with a lot of appeals by patients' families.
5
CT has made good progress with VBID in it HEP plan for state employees, now gaining traction in the commercial (private) market there. Great leadership from CT Office of State Comptroller and the State Innovation Model office.
Gets the right care, to the right patient, from the right provider.
Gets the right care, to the right patient, from the right provider.
1
I'll give you one that's got data behind it: in Alberta, Canada, where the insurance is government-funded, there's significant pressure to cut costs. So, the province invested in public health nurses - basically visiting nurses. When you have a baby, the first morning you're home, in comes public health. They stay about 90 minutes, do a checkup, nursing help, remove stitches/staples, help with a first bath. Then they come back 3 days later, just to see how you're coping. If there's a problem, they're authorized to come as many as 7 times. Sound expensive? They cut re-admission rates of newborns by almost 60%! As my nurse said "100 bucks an hour for us, including transportation, supplies and administration, vs 3k a day for hospitalisation? It's a really easy call!"
23
How can we get to the point of having the administratively simple and effective way of handling healthcare like this? It is so sensible.
3
This kind of system can be done, and has been, by assigning point values based on certain criteria. For example, a treatment that is lifesaving gets more points than one that is elective. A treatment with a long track record of success gets more points than one that is more experimental. So, for example, targeted antibiotics for pneumonia gets a high value score, because they are potentially lifesaving, and have a high likelihood of success. Surgery for back pain is not lifesaving though it could prevent or relieve disability, and many studies have found the benefits dubious compared to less invasive treatments such as physical therapy. So the score would be lower.
Where it really gets sticky, and where the real potential for cost savings lies, is in applying this principle to end-of-life care. Do you still treat pneumonia with antibiotics when the patient is dying anyway? Do you use expensive chemotherapy medications when they will extend life only a few months at most? "Value" toward the inevitable end of life is much harder to determine, and might need different criteria. It also faces the most resistance from patients or families in denial who want everything possible done, or will give anything for a few more months. Yet this is when the greatest spending occurs and where reining in costs for medically futile care could have the greatest impact. I hear the cries of "death panels" already, but this is where the real conversation needs to happen.
Where it really gets sticky, and where the real potential for cost savings lies, is in applying this principle to end-of-life care. Do you still treat pneumonia with antibiotics when the patient is dying anyway? Do you use expensive chemotherapy medications when they will extend life only a few months at most? "Value" toward the inevitable end of life is much harder to determine, and might need different criteria. It also faces the most resistance from patients or families in denial who want everything possible done, or will give anything for a few more months. Yet this is when the greatest spending occurs and where reining in costs for medically futile care could have the greatest impact. I hear the cries of "death panels" already, but this is where the real conversation needs to happen.
8
It's so easy.
Educating people is a lot less expensive than fixing their health problems. How many people know how to recognize a stroke? How many know how to loewer cholesterol by diet?
Giving financial incentives may help too. Make the health insurance premium to some extend dependable on the physical condition of the insured. You want lower premiums? Go to the gym!
Educating people is a lot less expensive than fixing their health problems. How many people know how to recognize a stroke? How many know how to loewer cholesterol by diet?
Giving financial incentives may help too. Make the health insurance premium to some extend dependable on the physical condition of the insured. You want lower premiums? Go to the gym!
5
I've been a gym member for over 30 years and I'm healthy. But I've found it's important to choose a gym where I feel comfortable with the other members and where I get classes, equipment and training that works for me. That's not always the cheapest gym in town or the closest. If I had a job with lots of face time, and a lot of family obligations, I couldn't do it ... assuming I could afford the membership.
2
No, it isn't so easy.
Most Americans already know how to lower cholesterol by diet—yet it's often cheaper for them to go on medication for that.
Most Americans already know how to lower cholesterol by diet—yet it's often cheaper for them to go on medication for that.
1
The Choosing Wisely campaign (choosingwisely.com) is composed of lists of over-used, often unnecessary medical modalities, compiled by different medical societies (e.g., American Academy of Pediatrics), in a consumer-friendly format, with useful explanatory material. Perhaps a health plan could use CW to "nudge" doctors and consumers away from care that is likely to be pointless, or even harmful (e.g., antibiotics for upper respiratory infections).
5
Choosing Wisely (http://www.choosingwisely.ORG) is an initiative of the ABIM Foundation (http://abimfoundation.org) in partnership with Consumer Reports (http://www.consumerreports.org/cro/health/doctors-and-hospitals/choosing....
My company gave me a $600 credit if my husband and I submitted to blood work, confirmed our weight and had our blood pressure taken at a quest lab. Now they know a lot more about our health. They know more than we do, as the results of these tests were never given to us.
Think about that...the large company is self insured.
They use a major insurance carrier to administer their plan.
There is Hippa but they own every part of this process and can now identify all those with high blood pressure, obesity, diabetes, heart disease, hyper tension, etc... and they can purge them out in the annual layoff.
How will anyone stay employed?
Think about that...the large company is self insured.
They use a major insurance carrier to administer their plan.
There is Hippa but they own every part of this process and can now identify all those with high blood pressure, obesity, diabetes, heart disease, hyper tension, etc... and they can purge them out in the annual layoff.
How will anyone stay employed?
21
Making individually identifiable data available to employers is a huge concern. As the founder of a startup, Personal Health Cloud that is enabling users to own their health data, this is an issue we've spent a lot of time discussing. While we want to make PHC available through corporate wellness programs and self-insurance programs, we're also addressing what can be shared and how it is shared.
Did you ask how, if at all, your individual test results might be shared with your employer? Did you try refusing to sign the HIPAA release forms? Did you ask that you be sent your test results? In many instances, when tests are ordered the results go to the provider who requested them and only shared with the patient when s/he specifically requests test results.
More and more, we have to take control of our health data, own it, and manage how it is shared.
Did you ask how, if at all, your individual test results might be shared with your employer? Did you try refusing to sign the HIPAA release forms? Did you ask that you be sent your test results? In many instances, when tests are ordered the results go to the provider who requested them and only shared with the patient when s/he specifically requests test results.
More and more, we have to take control of our health data, own it, and manage how it is shared.
10
Thanks for the advice
It is very much appreciated
It is very much appreciated
1
The truth is that these tests have little vale for adults without symptoms. See Gilbert Welch's books Overdiagnosed and Less Medicine More Health. Apart from privacy concerns, you could be harmed by treatment for a false positive.
It would have been useful if the article had included a table identifying the most common "high value" and "low value" care.
13
It sounds like the are using the "medical necessity" bar. If a doctor says a sleep test is a medical necessity, then it would be covered at a higher rate. If not, it would have a higher copay. If a doctor says an endoscopy is medically necessary, it would have a lower copay than if you insisted on having one despite your doctor saying you don't need it. A good system except that we all know many cases where doctors have ignored or missed symptoms that later turn out to be a real problem.
I'm learning the hard way that as a medical 'consumer' I don't have much say over the cost of my care. The best I can do is select an in-network doctor. After that, s/he decides what tests I have and where I will have them - if I don't submit to the tests, I have no hope of ever moving on from testing to a treatment plan. I have now had over $10,000 in tests (that's what insurance has paid, not what was billed) and I still haven't been offered a treatment plan. So what am I supposed to do? Go to another doctor and start over?
5
You can also shop around for tests and procedures at other facilities. My doctors are Cleveland Clinic but for routine blood work, diagnostics and outpatient procedures, I do not use their labs because of costs. There is a local lab that is significantly less expensive and provides high quality services. It's worth looking into.
6
I think you need to pick a new doctor.
2
The problem with any govt involvement in anything, including healthcare, is this: 85% of the money taken from taxpayers goes into the pockets of layers of bureaucrats.
Traditional Democratic voters seem unwilling to admit that pouring more money into healthcare or education or whatever just enriches a few at the top of each system and spawns more layers of bureaucrats.
Traditional Republican voters then take the polarized option: cut off all money for gov't programs.
Traditional Dems are going to need to lead the way by putting tight legislative controls on who gets tax money (ie no public school employee, including the superintendent, should make more than 3 times the average teacher salary for that district, etc).
If Dems would stop opposing Trump and come up with better ideas than his instead, Americans would get behind them--as long as waste, fraud, and excessive salaries were attacked and ended.
Traditional Democratic voters seem unwilling to admit that pouring more money into healthcare or education or whatever just enriches a few at the top of each system and spawns more layers of bureaucrats.
Traditional Republican voters then take the polarized option: cut off all money for gov't programs.
Traditional Dems are going to need to lead the way by putting tight legislative controls on who gets tax money (ie no public school employee, including the superintendent, should make more than 3 times the average teacher salary for that district, etc).
If Dems would stop opposing Trump and come up with better ideas than his instead, Americans would get behind them--as long as waste, fraud, and excessive salaries were attacked and ended.
3
Perhaps you could explain how the United Kingdom covers all of its citizens from birth to death with high quality, evidence based medicine. How they ensure that UK citizens live longer healthier lives than Americans and spend less than half as much per person on healthcare. Please no anecdotes about denied treatments, waiting lists or death panels - the numbers don't lie. Brits live longer, healthier lives and they pay half as much for their medicine.
The problem is not government - it's bad government. Republicans do everything they can to create government dysfunction so that they have an excuse to cut taxes.
The problem is not government - it's bad government. Republicans do everything they can to create government dysfunction so that they have an excuse to cut taxes.
9
"85% of the money goes to bureaucrats" is just not true. Maybe 15%, and that's too much, but still the facts are against you.
14
Noooo, 85+ percent of what you pay to a private insurer goes to pay for doctors, hospitals, meds, equipment and more. That's the law of the land (ACA).
11
The real issue is that the boomers are going to die off and rather than let their wealth transfer to their children, the medical-insurance
companies are going to force it from the boomers hand to the companies for their end of life care.
Anything experimental has no proven value, so how would anything new ever be covered unless it was cheaper?
The GOP is all about the destruction of the swamp (=lower and middle classes).
companies are going to force it from the boomers hand to the companies for their end of life care.
Anything experimental has no proven value, so how would anything new ever be covered unless it was cheaper?
The GOP is all about the destruction of the swamp (=lower and middle classes).
2
I didn't think the authors don't want single payer (not clear in this essay), they were addressing the situation as it is. To some extent, didn't Obamacare do this, with no copay screenings such as mammograms?
Also, it's not that suddenly some medical conditions have no value (e.g., yes, toenail fungus can be tortuous), it's about copays. While some conditions are unpleasant, they could still incur a copay for treatment. Maybe $20, maybe $200). Maybe the first copay is $200 and subsequent copays could go down. At the same time, some other conditions would npw have no copay because getting people to follow healthful behaviors - that reduce morbidity and mortality and maybe even save money - may improve more by removing the barrier.
Also, it's not that suddenly some medical conditions have no value (e.g., yes, toenail fungus can be tortuous), it's about copays. While some conditions are unpleasant, they could still incur a copay for treatment. Maybe $20, maybe $200). Maybe the first copay is $200 and subsequent copays could go down. At the same time, some other conditions would npw have no copay because getting people to follow healthful behaviors - that reduce morbidity and mortality and maybe even save money - may improve more by removing the barrier.
got toenail fungus??/ bleach water soaks 10:1 solution. 10 minutes 3 times daily
problem solved--cost, about 5 cents a day
problem solved--cost, about 5 cents a day
Since I did not go to medical school, I'd like to let my physicians decide on a treatment plan...wow what an idea! Certainly not an insurance company that has a huge conflict of interest by not treating me to save money. Or me, an ignorant consumer who, as everyone knows, only has the internet to offer insight into a thousand possibilities to feed my hysteria.
14
So, you are trusting your treatment entirely to someone who has a financial motive for prescribing test after test, which, lo and behold, can be done right there in the clinic. Instead of letting a whole bunch of doctors who constantly review the latest medical research (U.S. Preventive Task Force, whose findings your insurer uses) weigh in on potentially low-return treatment. And at the same time, you demand lower insurance premiums even though you want all the medical care in the world. Riiiight.
5
Actually, I belong to an HMO system (kaiser) have for many years. An affordable senior advantage plan. All inclusive plan with clearly stated co pays and test fees. My doctors in this plan have been great and I have not had the slightest sense that that order more tests, medicines or procedures. Too bad the rest of the US doesn't have this option. My premium actuallly went down this year.
5
I was in Group Health in Seattle and also had a positive experience. Wish we had them in Philly!
1
Give me a break! Single-payer Medicare for all. What, Dr. Frakt, is so difficult to understand about that?
Seriously. Do you really not get that single-payer is what we need?
Seriously. Do you really not get that single-payer is what we need?
16
What is high value and who decides?
Glaucoma testing and medication; diabetic exams for eyes, feet, heart, dental? MRIs for people who have neurological vision loss? MRIs for people who have sciatica? Eliquis instead of coumadin? Januvia instead of metformin?
Medications which cost the earth but cure Hep C or cancer? End of life emergency care?
I agree that we should be triaging medical procedures and focusing on assuring the necessary treatment comes before the less necessary.
But can anyone say who should be the arbiter of what is high and low value care? Figure that one out, and we have solved a fundamental national problem in cost and care.
Glaucoma testing and medication; diabetic exams for eyes, feet, heart, dental? MRIs for people who have neurological vision loss? MRIs for people who have sciatica? Eliquis instead of coumadin? Januvia instead of metformin?
Medications which cost the earth but cure Hep C or cancer? End of life emergency care?
I agree that we should be triaging medical procedures and focusing on assuring the necessary treatment comes before the less necessary.
But can anyone say who should be the arbiter of what is high and low value care? Figure that one out, and we have solved a fundamental national problem in cost and care.
10
The National Center for Health Statistics collects data that describes injuries and I believe the results of treatments. Having the data allows people to review the problems and solutions; not everyone would agree with the rankings, and there will be changes in categories and ranking as we learn. It will not be perfect; the perfect is is enemy of the good, but it will be rational.
It's certainly time to stop covering useless procedures such as meniscus surgery and some back surgeries altogether.
@NorCal: Meniscus surgery is "useless"? Are you a doctor or a medical researcher? I didn't think so!
My meniscus surgeries are the reason I'm able to walk around today. Do you think 2 full knee replacements would have been cheaper? You clearly know nothing about knee injuries!
My meniscus surgeries are the reason I'm able to walk around today. Do you think 2 full knee replacements would have been cheaper? You clearly know nothing about knee injuries!
12
Arthroscopic surgery on my left knee (meniscus tear) gave me complete cessation of pain (after a long recuperation) and freedom to run, walk and do steps for 10 years.
Is that worth anything?
Is that worth anything?
3
Who should decide the "value" of these services, anyway?
2
On at least one of Aetna's Medicare Part D prescription drug plans, their pricing strategy incentivizes smokers to not quit. The insurer classifies the smoking-cessation medicine Chantix as a 'Tier 4' drug, which covers only 20% of the cost.
A monthly copay of $220 or more? I think many on Medicare with lower incomes might decide to roll the dice and just keep smoking.
A monthly copay of $220 or more? I think many on Medicare with lower incomes might decide to roll the dice and just keep smoking.
10
.. well, having had a father who contracted toenail and foot fungus ("athletes feet") during his WWII service and that plagued him, and often caused him considerable pain, until he died, I'd say that for him, had the treatment now available for this fungus been available when he was living, it would have held a high priority and value for him. "Valuing" of treatment is not something that can be done well through statistics only.
24
I had miserable, agonizing pain and discomfort, including sores and itching so bad it affected my sleep, from foot fungus. Over time, it moved onto my toenails, where it was not just disfiguring, but was making the toenails brittle and crumbly, leading to infections under the nail.
This was treated and 100% CURED (after 40 YEARS of misery) by the then-new drug Lamisil. A 90 day course of treatment, and disfiguring and embarrassing lesions and open itchy sores on my foot literally dried up and disappeared. That was 18 years ago. It has never reoccured. I think this was a very good use of medication, one time and it cured a fungal infection that had resisted every other treatment (and countless dermatologists and podiatrists ) and medication for 4 decades.
It's easy to make fun of such stuff -- feet! how funny! -- but your feet are a critical component of your skin health, ability to walk and function.
Very few meds I have ever taken for any reason have been as effective and the cure PERMANENT as this one was.
This was treated and 100% CURED (after 40 YEARS of misery) by the then-new drug Lamisil. A 90 day course of treatment, and disfiguring and embarrassing lesions and open itchy sores on my foot literally dried up and disappeared. That was 18 years ago. It has never reoccured. I think this was a very good use of medication, one time and it cured a fungal infection that had resisted every other treatment (and countless dermatologists and podiatrists ) and medication for 4 decades.
It's easy to make fun of such stuff -- feet! how funny! -- but your feet are a critical component of your skin health, ability to walk and function.
Very few meds I have ever taken for any reason have been as effective and the cure PERMANENT as this one was.
6
Who gets to decide what medical treatment has value? Sleep studies result in treating sleep disorders, which can cause life threatening conditions. We need to pay for ALL medical and dental care. Single payer.
24
There isn't a single payer system out there that pays for everything. The money has to come from somewhere, the government can't just print it up.
7
Who decides is a panel of doctors who examine peer-reviewed research on procedures and medications. This is often an independent panel with no financial motivation. Also, insurers use the treatment guidelines issued by the US Preventive Task Force, which does the same thing - examines peer-reviewed research for what treatments are most effective, and which ones seem to have minimal benefits.
12
@Moira: Oh, but the government can and DOES "just print [money] up" all the time!
5
How about value-based payments to doctors? So a general surgeon would get paid more than $500 for an appendectomy and an orthopedist would get less than $3500 for an arthroscopic meniscectomy?
11
Just adding administrative complexity and cost. As George McGovern observed: It's simple. Medicare for All.
30
can someone please explain how to measure the "health benefit" or a service wrt healthcare? take your time
2
Am J Manag Care. 2015 Mar;21(3):221-7.
Developing a composite weighted quality metric to reflect the total benefit conferred by a health plan.
Taskler GB1, Braithwaite RS.
Abstract
OBJECTIVES:
To improve individual health quality measures, which are associated with varying degrees of health benefit, and composite quality metrics, which weight individual measures identically.
STUDY DESIGN:
We developed a health-weighted composite quality measure reflecting the total health benefit conferred by a health plan annually, using preventive care as a test case....
RESULTS:
Our composite quality metric gave the highest weights to health plans that succeeded in implementing tobacco cessation and weight loss. One year of compliance with these goals was associated with 2 to 10 times as much health benefit as compliance with easier-to-follow preventive care services, such as mammography, aspirin, and antihypertensives. For example, for women aged 55 to 64 years, successful interventions to encourage weight loss were associated with 2.1 times the health benefit of blood pressure reduction and 3.9 times the health benefit of increasing adherence with screening mammography.
CONCLUSIONS:
A single health-weighted quality metric may inform measurement of total health system performance.
Developing a composite weighted quality metric to reflect the total benefit conferred by a health plan.
Taskler GB1, Braithwaite RS.
Abstract
OBJECTIVES:
To improve individual health quality measures, which are associated with varying degrees of health benefit, and composite quality metrics, which weight individual measures identically.
STUDY DESIGN:
We developed a health-weighted composite quality measure reflecting the total health benefit conferred by a health plan annually, using preventive care as a test case....
RESULTS:
Our composite quality metric gave the highest weights to health plans that succeeded in implementing tobacco cessation and weight loss. One year of compliance with these goals was associated with 2 to 10 times as much health benefit as compliance with easier-to-follow preventive care services, such as mammography, aspirin, and antihypertensives. For example, for women aged 55 to 64 years, successful interventions to encourage weight loss were associated with 2.1 times the health benefit of blood pressure reduction and 3.9 times the health benefit of increasing adherence with screening mammography.
CONCLUSIONS:
A single health-weighted quality metric may inform measurement of total health system performance.
4
@5barris: I have one response to you: bell-curve.
3
The problems illustrated in this article were addressed in the ACA (aka ObamaCare).
All the ACA needs to be great is some tweaking, just as is always the case with any program that affects so much of a nations economy.
The cacophony of republickan whining about ObamaCare can be summarized in one paragraph:
"We want the entire non-system of treating over 50 million Americans in Emergency Rooms to be fully restored to as it was prior to 2010.
Ya know, when those ridiculously overpriced and often too late medical treatments were completely absorbed by the local homeowners through their "hospital district" real estate taxes".
All the ACA needs to be great is some tweaking, just as is always the case with any program that affects so much of a nations economy.
The cacophony of republickan whining about ObamaCare can be summarized in one paragraph:
"We want the entire non-system of treating over 50 million Americans in Emergency Rooms to be fully restored to as it was prior to 2010.
Ya know, when those ridiculously overpriced and often too late medical treatments were completely absorbed by the local homeowners through their "hospital district" real estate taxes".
24
United States still stuck in mid-20th Century, trying to make for-profit health insurance work for the benefit of executives and shareholders. Sad.
59
Do you really want to charge for vaccinations?
So much for the herd protection
So much for the herd protection
21
As a professor of economics I see the sense in a value-based approach.
So, last year when I suggested that a funny looking patch of skin on my arm be tested for cancer, I was given a choice. The choice was to get the biopsy and if it was positive the test would be covered, if it was negative the cost would be $250.
I am still trying to figure out the rational reasoning behind this.
So, last year when I suggested that a funny looking patch of skin on my arm be tested for cancer, I was given a choice. The choice was to get the biopsy and if it was positive the test would be covered, if it was negative the cost would be $250.
I am still trying to figure out the rational reasoning behind this.
43
I guess that's the classic goodnews/badnews. Bad news: you have cancer. Good news: you don't have to pay for that biopsy!
14
If your doctor thought you needed the biopsy, it would have been paid for.
If I walk into my doctor with no symptoms of strep throat and my doctor examines me and does not see any sign of strep throat, I should be charged if I still insist on being tested for it.
If I walk into my doctor with no symptoms of strep throat and my doctor examines me and does not see any sign of strep throat, I should be charged if I still insist on being tested for it.
1
I live in Switzerland, with mandatory health insurance for all (a.k.a. the dreaded "socialized medicine"). I, too, found a suspicious spot on my leg. I immediately made an appointment, it was very early stage melanoma. I needed follow-up surgery and will have to have whole body dermatological checks every six months from now on. However, since I caught it so early, there was no danger of spreading.
The only thing that would have been accomplished had I waited to remove the suspicious mole would have been cancer at a much more developed stage.
And I needed to stay home from work for two weeks after the wide local excision because it was in an area with very little skin (over the Achilles tendon). Fortunately, there is mandatory sick leave here as well.
PJM, go for the test even if an idiot at an insurance company wants you to pay for it if it is negative. It might save your life.
The only thing that would have been accomplished had I waited to remove the suspicious mole would have been cancer at a much more developed stage.
And I needed to stay home from work for two weeks after the wide local excision because it was in an area with very little skin (over the Achilles tendon). Fortunately, there is mandatory sick leave here as well.
PJM, go for the test even if an idiot at an insurance company wants you to pay for it if it is negative. It might save your life.
3
They repeated sleep studies as an example overused procedure. It raises an interesting point. Sleep apnea won't typically kill you near term but will make you a less productive employee and kill you long term when you are most likely not employed by your employer any longer
13
I've read there's also neurological damage that accompanies the more severe cases. Good point though - if "high value" is defined as, "patient is immediately better" with immediate being a month or three, then a lot of stuff that really is necessary will get swept under the rug.
3
Sleep apnea is a HUGE problem; it can most definitely kill you. If not directly, than through harming your heart and your overall health. Not to mention, the pure misery of being tired and cranky and listless, for years and years.
It runs in my husband's family, but I also know other people who have it. It's more common than folks realize.
It is a shame this article trivializes it. You CANNOT get a CPAP machine nor treatment for sleep apnea, WITHOUT A SLEEP STUDY.
It runs in my husband's family, but I also know other people who have it. It's more common than folks realize.
It is a shame this article trivializes it. You CANNOT get a CPAP machine nor treatment for sleep apnea, WITHOUT A SLEEP STUDY.
1
How about those of us who have such choices, eat better, exercise, get good quality rest, etc. Radial huh? There are those of us who are actually doing that---and we are not at the high end of the pay scale by any means. A whole lot of the chronic illnesses could be avoided or reduced by simply making better choices each day. It's not rocket science. It's common sense. Which there seems to be in shorter supply than good insurance ideas. There will always be those who abuse themselves and any system. Get over it and get on with it. We are the only industrialized nation that can't seem to figure this out. Health care should not be a free market item. In the US everything is commodity driven. Human health and well being is not a commodity.
14
Not much choice in whose genes and money you inherited and what toxic Superfund site your parents decided to build your childhood home on for the cheap mortgage and the good schools. Or who is driving the car heading towards you and how drunk or distracted they are.
By all means, don't smoke or overeat and exercise, but just because it's worked for you so far, don't count on it forever (and don't assume your good living is all that's between you and THEM).
And keep up with whatever insurance you got going, even if the GOP gives you a cheap option that doesn't cover all those health problems you associate with bad choices.
By all means, don't smoke or overeat and exercise, but just because it's worked for you so far, don't count on it forever (and don't assume your good living is all that's between you and THEM).
And keep up with whatever insurance you got going, even if the GOP gives you a cheap option that doesn't cover all those health problems you associate with bad choices.
40
meg: how could you tell about most of those things? What if I told my doctor "sure I walk 2 miles a day and never eat sugar" -- how could that be proven, outside of my word on it? And if I was incentivized by huge charges for NOT saying those things, of course I would say them -- true or not!
2
Have always been a vegetarian, the right weight, not a smoker or drinker, exercised, slept well and none of this prevented getting angina several years ago. Was then diagnosed with Familial Hypercholesterolemia and now take a very expensive drug- Praluent. Genetics play a large role in many cancers and other illnesses as does environment. ''Better choices'' don't always work. This is actual science which is different than ''common sense'' which is just what people think at any given moment in time- think boiling oil poured in one ear for earaches during the middle ages. Stop blaming patients for needing medical treatments - you don't know anything about the causes of their illnesses and often the medical profession is also ignorant- anything ''idiopathic'', for instance.
4
Why is cancer care listed under the category of "value" medicine? The treatments are ludicrously expensive and inefficacious.
7
Another day, another health column "rearranging the deck chairs while the Titanic is sinking".
Is America forever doomed to be "exceptional" in bankrupting and killing its citizens in support of for-profit medicine ?
Medicare for all, and government negotiation of medicare drug prices based on efficacy (like the UK's NICE).
Is America forever doomed to be "exceptional" in bankrupting and killing its citizens in support of for-profit medicine ?
Medicare for all, and government negotiation of medicare drug prices based on efficacy (like the UK's NICE).
55
In the UK with NICE, the National Health Service wouldn't offer a patient the choice of an inappropriate treatment like back surgery or unnecessary imaging for a $500 fee.
The NHS wouldn't pay for it at all. Why should you pay *anything* for an inappropriate service that can only do you more harm than good?
The NHS wouldn't pay for it at all. Why should you pay *anything* for an inappropriate service that can only do you more harm than good?
9
The NHS in the UK is a mess. Any funding increases go straight into the pockets of bureaucrats who nitpick doctors and layer on the paperwork. People wait weeks to be seen by doctors and any surgery deemed by the bureaucrats to be "elective" is subjected to constant postponement.
The exact same scenario would play out here. People are incredibly clueless about what really happens with the NHS.
The exact same scenario would play out here. People are incredibly clueless about what really happens with the NHS.
Honeybee you are the one who is clueless- I doubt you've ever had medical care in the U.K. The NHS spends much less per patient and has much better health outcomes, less doctor and hospital errors, longer lifespans. The NHS is absolutely not a mess. I was treated in Britain in a timely manner and had excellent care. U.S. patients must wait for several weeks to be seen and several more weeks to months to obtain a surgery that is not an emergency. There is way more paperwork here- just ask your doctor! In the UK, you just show up for your appointment, you never see a bill, you never fill out any paperwork and you get reimbursed for your transportation.
5
One problem with V-BID is that it fails to consider real home economics. Half the people in the U.S. have just 1% of family wealth. The few who have the time and intelligence to study the system might change their health care behavor. Most of us don't have the time or the knowledge; or the savings is not worth the effort. The other problem is that it is controled by the profit making insurance companies.
12
I am not unsympathetic at all to those truly less fortunate. That was how I grew up - lower middle class. But, the idea that people are permanently pigeonholed to such lives (upward mobility still does exist) and/or don't have the time or intelligence to figure out how to make wise choices within the current framework is faulty. No disagreement however that the current system is garbage. There is a very good Bloomberg business week article on the pricing of prescription drugs that is eye opening - see insulin price gouging. It is a bizarre structure that needs material streamlining that would be helped by added transparency, competition and market forces (in addition to regulatory oversight). In addition, we should have some level of baseline care for all, and private insurance for those that want added care. That is how other countries do it, and we have to get to that model.
17
There is a correlation between IQ and success. Those below 85 IQ have a hard time in most economic calculations - even in the supermarket. V-BID is too complex to work for all and the insurance companies reap the profits.
As for prescription drugs, the market is inelastic. A given number of people need a given type and quantity of drugs. Pharmaceutical companies have no incentive for quick cheap cures or developing medication for rare disease. Weight loss drugs are more profitable.
We need more competition in primary care and we need socialized (single payer) prescription medication for all. Let all taxpayers reap the benefit of advances in medications. Let the market encourage providers to be as competent and efficient as possible.
As for prescription drugs, the market is inelastic. A given number of people need a given type and quantity of drugs. Pharmaceutical companies have no incentive for quick cheap cures or developing medication for rare disease. Weight loss drugs are more profitable.
We need more competition in primary care and we need socialized (single payer) prescription medication for all. Let all taxpayers reap the benefit of advances in medications. Let the market encourage providers to be as competent and efficient as possible.
5
I wouldn't say the market for drugs is inelastic. Pharma is all the time coming up with new "conditions" that they just happen to have drugs already to treat them.
2
Our big problem is high overall costs. Each medical procedure in the US costs 2-3 times as much as in rich countries like Germany and Switzerland. If we only had to pay what they're paying, we'd be able to afford medical care.
Cutting overall costs would not be easy, but right now no one is even trying to do this.
Cutting overall costs would not be easy, but right now no one is even trying to do this.
22
Nonsense. Enormous savings in
1) reducing the administrative costs inherent in the multi-payer (private insurance companies) approach and
2 centralized negotiating for pharmaceuticals and providers fees.
1) reducing the administrative costs inherent in the multi-payer (private insurance companies) approach and
2 centralized negotiating for pharmaceuticals and providers fees.
9
Since every other developed country provides cheaper healthcare to its citizens than the US---and with better outcomes, typically---the problem is not generating options for controlling costs. Those other countries have provided us with examples of how to do it. The problem in the US is getting congressmen from the Red states to put their slogans aside and to actually look at the options available.
21
I'm guessing a lot of blue staters also have lobbyist-based "reservations". The US is the last major holdout of the "pay or die" system with it's accompanying "charge tons of money to provide funds", i.e., own stock in an insurance company, system.
2
Those who have drunk the "individual responsibility" cool-aid are constantly coming up with nudges like this, in attempt to salvage that conviction. People are not saving enough for retirement, so lets make 401k-contributions the default. People choose healthcare options badly, so lets stack the deck. Tax breaks for doing "the right thing".
Imagine if, like our position on primary school, we just came to terms with the conclusion that these are important issues for most all individuals and instead of tangles of tax breaks and special rules to nudge & coerce, we simply defined a flat and universal base of support for all.
Imagine if, like our position on primary school, we just came to terms with the conclusion that these are important issues for most all individuals and instead of tangles of tax breaks and special rules to nudge & coerce, we simply defined a flat and universal base of support for all.
54
Bottom line, health care should be affordable. it is a right, not a privilege.
It doesn't mean it should be free. If you eliminate reasonable deduct., co payment etc. you get abuse with the hypos going for every known pill, treatment etc.
Ditto for people who abuse their bodies. People who smoke should be at the bottom of the lung transplant list.
It doesn't mean it should be free. If you eliminate reasonable deduct., co payment etc. you get abuse with the hypos going for every known pill, treatment etc.
Ditto for people who abuse their bodies. People who smoke should be at the bottom of the lung transplant list.
7
It seems to me that the "stick" approach described here does address the potential for abuse by making non-essential care more expensive.
No one is going to abuse insulin. You'd only get one physical per year. The most dedicated hypochondriac will probably hesitate to pay more out-of-pocket for multiple sleep studies (and if they proceed, it's on their dime, so what's the difference?) No one is going to go on an antidepressant binge.
Speaking of which: People who smoke often do so because nicotine relieves depression and anxiety, and unless they have good insurance they can't afford counseling or antidepressants. Same thing for many people who overeat their way to diabetes and heart disease. Both smoking and obesity are more common among lower-income Americans, who struggle just to keep up with their bills--a source of anxiety and depression. Let's not set out to punish them more, okay?
And can we please grab the idea that "we mustn't make anything better for the majority if there's a chance of abuse," by the neck, drag it out behind the barn and shoot it? It's a terrible way to make policy, leaving millions in misery because a handful of people MIGHT get something for nothing.
No one is going to abuse insulin. You'd only get one physical per year. The most dedicated hypochondriac will probably hesitate to pay more out-of-pocket for multiple sleep studies (and if they proceed, it's on their dime, so what's the difference?) No one is going to go on an antidepressant binge.
Speaking of which: People who smoke often do so because nicotine relieves depression and anxiety, and unless they have good insurance they can't afford counseling or antidepressants. Same thing for many people who overeat their way to diabetes and heart disease. Both smoking and obesity are more common among lower-income Americans, who struggle just to keep up with their bills--a source of anxiety and depression. Let's not set out to punish them more, okay?
And can we please grab the idea that "we mustn't make anything better for the majority if there's a chance of abuse," by the neck, drag it out behind the barn and shoot it? It's a terrible way to make policy, leaving millions in misery because a handful of people MIGHT get something for nothing.
29
Here's a nutty idea from a tenured consumer healthcare advocate:
How about having our government regulate the price of all drugs, especially those used to treat chronic conditions?
Insulin can cost upwards of $400 per month, and because of that 29 million people (according to NPR) simply can't afford it and go without.
If we truly want to improve outcomes, we need to reign in the skyrocketing costs of life saving medications. It is pathetic that other civilized nations refuse to let their patients be price gouged, but we seem to welcome it.
How about having our government regulate the price of all drugs, especially those used to treat chronic conditions?
Insulin can cost upwards of $400 per month, and because of that 29 million people (according to NPR) simply can't afford it and go without.
If we truly want to improve outcomes, we need to reign in the skyrocketing costs of life saving medications. It is pathetic that other civilized nations refuse to let their patients be price gouged, but we seem to welcome it.
61
Agreed Sarah...health care should be affordable. It is a de facto crime what is going on in this country.
However, it should not be free either or you get the abuse from the other end by patients.
However, it should not be free either or you get the abuse from the other end by patients.
3
Paul, I do believe there are a myriad of drugs that could be given at no/low cost (such as birth control and cholesterol meds) that won't be abused. Still, I concede that those that are typically abused (opioids) must be closely monitored.
Other countries have figured this out. The government agencies that do the research and find solutions just to hand them off to for profit pharmaceutical companies to price gouge us are not doing patients any favors. Further, the inflated costs we are forced to pay, in part, are bankrolling the rest of the world.
Other countries have figured this out. The government agencies that do the research and find solutions just to hand them off to for profit pharmaceutical companies to price gouge us are not doing patients any favors. Further, the inflated costs we are forced to pay, in part, are bankrolling the rest of the world.
34
Basically agree Sarah...We have a de facto criminal health care for profit program ie, don't get sick and/or be rich, and/or don't have a bad life event while drug czars become billionaires.
However, patients and outright crooks can also abuse the system.
However, patients and outright crooks can also abuse the system.
4