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Comments
When I go to the hospital
When I go to the hospital now I am concerned that a doctor will run me through a gamet of expensive procedures (I have GREAT insurance now but used to have no insurance and bad insurance I see the obvious difference in care.) With this proposal now I fear that I will be pushed aside instead and not offered any treatments even when it could be useful for me.
This new system scares me because I feel that my doctors will reverse that course and give me none of the treatment that I will need.
So I either get too much or not enough, where is my middle ground.
it absolutely could make a difference
Yesterday I heard a physician give a great talk about this and related topics. It's all about incentivizing. A flat per patient amount means that health care providers have an incentive to hold down costs by cutting back on what could be -- at least at the margins -- important procedures, while per procedure means that each event brings in revenue, though amounts may vary.
Somewhere there's gotta be a blended approach that recognizes both patient care and economics, but I can understand why there is real concern over this.
I've heard from some
I've heard from some opponents to health care reform that if 50 million more people become insured, there won't be enough doctors for them. Frankly, that sounds like a solution to this problem.
Assuming a physician needs X procedures to bring in sufficient revenue, if they have more patients, you don't need to give extra procedures to patients who don't need them, you can reach X procedures much more easily as you'll have more patients who really do need those procedures.
They could do it the way some states do car insurance
Divide people into categories based on their recent health.
PCPs could each have a quota of high-maintenance (I don't mean that to refer to the personality type!) patients, middle-maintenance, low-maintenance, etc.
Or there could be tiers of patient types, so if a PCP prefers to largely see a specialty group who come in a lot, such as people living with HIV, or athletes, or people with a psych diagnosis, that person wouldn't have to have as many patients as someone who has a lot more people who come in once a year for their physical if even that.
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http://1smootshort.blogspot.com
Yeah, there needs to be a balance
I have really crappy insurance that costs me a decent chunk, but my employer is paying 70% of the premium, so anything I could buy for my 30% would be much much crappier.
My PCP at Fenway is a nurse practitioner with a community health center approach to things. She knows my situation, and she knows how much they bill for various tests, and listens to me when I tell what is and isn't covered. She's honest with me about what I really really need and need to find a way to pay for, and what I could go without. She'll also code things so they get paid for if there's a way to do that that isn't dishonest.
Just about every other doctor I see doesn't have this sort of practice whatsoever, and they have no idea how much things cost. I often have ballpark figures from having seen my bills, and they'll tell me they had no idea it cost anywhere near that. Doctors in ERs especially want to run every single thing right then and there at the inflated ER rate, and aren't very sensitive to my saying that I have to pay it out of pocket. They start labeling people as "noncompliant" when we try to discuss what absolutely needs to be done and what we can choose not to do. I'm positive that some of it is financially motivated, because it seems that doctors have been taught that with X symptom, you do A, B, and C, and you don't need to bother learning which one to leave out if the person can't pay for it. Taking the financial incentive out might help things.
In the mental health world, when I see someone whose insurance I'm not in network for, I have to do a clinical review every 15 sessions. That means I call and speak to a clinician who works for the insurance company, and we discuss what I'm doing and whether it's necessary. Even when I'm in network, or being paid out of pocket or working pro bono, I have to have a written, detailed treatment plan that explains why my approach is appropriate to what's going on with the person, and why another less-expensive type of treatment can't be done instead. It doesn't meet standards of practice to just say that it improves quality of life or that the person reports that they feel better when they have my services. Some of these requirements are a bit over the top and are examples of why we don't have true mental health parity (the idea that mental health services are provided as freely as physical health services by all insurers), but it might be a good idea to require that physicians also explain in detail why their services are necessary, cost-effective, and evidence-based.
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http://1smootshort.blogspot.com
Oh, also
There needs to be something in place so that physicians don't have to practice defensive medicine. It's ridiculous that people can waste a doctor's time suing for failing to perform every single test every time someone has a symptom. Along with the more in-depth treatment plans should be some sort of safeguard where if the treatment plan is appropriate and reasonable for what's being presented, someone can't file a suit because the doctor failed to recognize that their cold symptoms were actually some rare disease that only 30 people have ever had?
(OK, how about they still can file it, constitutional rights and all, but they're not going to because they'll clearly have to pay the doctor's legal fees and missed time at work due to having filed a frivolous lawsuit?)
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pay when you're sick
The basis of paying for doctors is you use them when you're sick, you're willing to pay somebody to make you feel better, or pay a lot to save your life. The rest of the time the body is generally doing its job -- you're going to pay the doctor for that?
Should that apply equally to everyone?
I fully support the decisions of people who choose not to go to doctors for preventative care. I find it offensive that some of the parents I work with are called "neglectful" and "noncompliant" when they choose not to take their children to a Western doctor solely because society dictates that that's what people do. (Fortunately, the law doesn't consider it neglect to choose not to take a healthy child to a doctor, and does consider it neglect to withhold treatment from a seriously ill or injured child). Personally, I go to doctors for conditions where I feel that Western medicine is the right approach, and I stay home and use proven home remedies for things where I don't feel that I need to pump myself with antibiotics. In some instances, I do some of both, and I've chosen Western docs who are open-minded yet upfront, and guide me nicely in my decisions.
We DO currently have a system where we pay when we're sick, unless we're living in poverty. They're called copayments. I'm not sure what you're suggesting, but it sounds like you want people to pay their entire medical bills? The cost that my insurance company pays to my providers every year is considerably higher than my yearly salary. I've got a few medical conditions, and am generally someone who lives a healthy lifestyle, works more than fulltime, etc. I have insurance so I have a way of paying for my medical care. And for stretches of time when I'm healthy, I'm supporting the system so it's around when I need it. And around when my neighbors need it. People who aren't doing this are freeloading and making everyone's insurance cost more. When an uninsured "but I'm healthy!" person gets in an accident and needs $100,000 of medical care, the hospital ends up writing it off. What they really should do is treat the person, then put them in a labor camp until they'd paid. There are two problems with that though: it's really sick and wrong to be putting people in labor camps, and it doesn't work for someone who has a severe disability that limits the person from doing pretty much any work. So the only realistic option is to have everyone pay for healthcare, and if they don't get sick, then that's a big benefit in and of itself. I don't resent paying for police officers, firefighters, or any number of other things I don't use. I consider myself lucky every day that I don't currently need to have my house saved or be helped because of a crime.
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http://1smootshort.blogspot.com
paying for doctors
I'm not advocating anything. I have gone three years at time without seeing my doctor, but he'll get paid for those years? Doctors do the most work on sick people. Sick people (rightly) demand the most from their doctors and are willing to pay. In fact there is little else in our country that is paid for in inverse relation to its use in the manner suggested here. I can't think of anything except the military.
Not quite like that
As I understand it, it would be more like doctors would be salaried, rather than paid extra when they run more tests than are probably needed.
I'm assuming there'd be some sort of productivity requirement; there wouldn't be a way for a provider to have a ton of patients who never come in and still make a full salary while sitting at home for months.
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http://1smootshort.blogspot.com