After the ACA: Freeing the market for health care

[BWV 1080]

Great article on how Obamacare, in its current form, is doomed to failure in its goal to reduce costs in the Healthcare system. If the GOP was not completely in the pockets of the healthcare industry they could have offered some better solutions centered around the distinction between health insurance for extreme events and routine health care (the latter should be paid directly by consumers)

the money quote is here:

The ACA and the health‐policy industry are betting
that new regulation, price controls, effectiveness panels, “accountable care” organizations, and so on
will force efficiency from the top down. And the plan is to do this while maintaining the current
regulatory structure and its protection for incumbent businesses and employees.

Well, let’s look at the historical record of this approach, the great examples in which industries,
especially ones combining mass‐market personal service and technology, have been led to dramatic cost
reductions, painful reorganizations towards efficiency, improvements in quality, and quick dissemination
of technical innovation, by regulatory pressure.

I.e., let’s have a moment of silence.

http://faculty.chicagobooth.edu/john.co ... er_aca.pdf

[John F]

Obamacare, in its current form, is doomed to failure in its goal to reduce costs in the Healthcare system. If the GOP was not completely in the pockets of the healthcare industry they could have offered some better solutions

"Obamacare" is largely a GOP-designed program, based on Romneycare. As for the national GOP, you should add "and if it was not completely opposed to anything that Democrats are for." That's a false hope.

better solutions centered around the distinction between health insurance for extreme events and routine health care (the latter should be paid directly by consumers)

Better for the insurance companies in the short run, perhaps, but worse for the "consumers," also known as everybody. Nothing discourages preventive and routine health care like having to pay doctors' fees out of your own pocket. Do you know what they cost? I paid $75 for a routine physical exam and more for the blood tests back when I was between employer-provided health insurance and Medicare, and that was years ago; it's probably over $100 now.

I said "in the short run," because if people aren't getting checkups and preventive care, many will eventually wind up with "extreme events" that cost much, much more.

[RebLem]

Great article on how Obamacare, in its current form, is doomed to failure in its goal to reduce costs in the Healthcare system. If the GOP was not completely in the pockets of the healthcare industry they could have offered some better solutions centered around the distinction between health insurance for extreme events and routine health care (the latter should be paid directly by consumers)

the money quote is here:

The ACA and the health‐policy industry are betting
that new regulation, price controls, effectiveness panels, “accountable care” organizations, and so on
will force efficiency from the top down. And the plan is to do this while maintaining the current
regulatory structure and its protection for incumbent businesses and employees.

Well, let’s look at the historical record of this approach, the great examples in which industries,
especially ones combining mass‐market personal service and technology, have been led to dramatic cost
reductions, painful reorganizations towards efficiency, improvements in quality, and quick dissemination
of technical innovation, by regulatory pressure.

I.e., let’s have a moment of silence.

http://faculty.chicagobooth.edu/john.co ... er_aca.pdf

Now, why do you suppose that no other country in the world, not even the inheritors of the legacy of that ole right wing favorite, Chaing Kai Shek on Taiwan, have ever gotten on to this secret? WOW, I'm so glad I live in America, where I will, if you have your way, have to pay all my own medical expenses until I am all but destitute so we can build another aircraft carrier, another nukey sub, and a whole raft of F-22's we will never use. Rah! Rah! Rah! USA! USA! Yippeee Kai Yay!

Oh, by the way, I hope you Texans succeed in seceding. That way we can put up a big, tall, barbed wire fence on the New Mexico/Texas border to prevent the current invasion of Texas feral hogs that you refuse to spend the money to control effectively.

[jbuck919]

I can't question his academic credentials, but I find the article poorly written, jumping all over the place instead of pursuing and supporting one line of reasoning, or a series of them. Also, it is premised on ACA going away, which didn't and will not happen. Steve has focused on one idea--that we only need major medical and not basic health insurance--that he happens to agree with (I do not, since we have already invented the deductible). However, anyone with any point of view on the subject can find some sentence in there and conclude "he agrees with me" without taking it out of context, since the author provides no context to begin with.

[BWV 1080]

Nothing discourages preventive and routine health care like having to pay doctors' fees out of your own pocket. Do you know what they cost? I paid $75 for a routine physical exam and more for the blood tests back when I was between employer-provided health insurance and Medicare, and that was years ago; it's probably over $100 now.

I said "in the short run," because if people aren't getting checkups and preventive care, many will eventually wind up with "extreme events" that cost much, much more.

If the majority of consumers had some financial incentive to shop around, then routine care would cost far less. Can you imagine what an oil change would cost if the government mandated you car insurer to pay for it and let the mechanics association set the licencing requirements to perform the service?

[BWV 1080]

I can't question his academic credentials, but I find the article poorly written, jumping all over the place instead of pursuing and supporting one line of reasoning, or a series of them. Also, it is premised on ACA going away, which didn't and will not happen. Steve has focused on one idea--that we only need major medical and not basic health insurance--that he happens to agree with (I do not, since we have already invented the deductible). However, anyone with any point of view on the subject can find some sentence in there and conclude "he agrees with me" without taking it out of context, since the author provides no context to begin with.

Routine health care is not "insurable" as everyone needs more or less the same quantity of it. It simply is an installment plan. Paying for it through higher insurance premiums than would otherwise be the case just distorts the prices incentives that would allow markets to supply better routine care at lower prices

[John F]

You and others speak of "shopping around" for health care services as though there were nothing to it. But there's much more to it than the doctor's fee: the doctor's reputation, his/her hospital affiliation, the convenience of his/her location, and more. Choosing a primary care physician from my Medicare Advantage's roster was complicated enough without additionally having to find out what each of the doctors charges for which services and weighing that against the other factors. I'm grateful that my Medicare coverage didn't require me to decide between the better doctor and the cheaper doctor.

The free marketeers always assume that shopping around for goods and services is a panacea. Where you've decided on a product like a Honda or a Maytag refrigerator, finding the vendor who will sell it to you for less is straightforward and the Internet actually makes it easy. When you're trying to decide on a product, between a Ford or a Honda, not so much. Doctors don't come off the same assembly line, every one of them is an individual "brand." Free market price pressures don't really apply.

[BWV 1080]

You and others speak of "shopping around" for health care services as though there were nothing to it. But there's much more to it than the doctor's fee: the doctor's reputation, his/her hospital affiliation, the convenience of his/her location, and more. Choosing a primary care physician from my Medicare Advantage's roster was complicated enough without additionally having to find out what each of the doctors charges for which services and weighing that against the other factors. I'm grateful that my Medicare coverage didn't require me to decide between the better doctor and the cheaper doctor.

The free marketeers always assume that shopping around for goods and services is a panacea. Where you've decided on a product like a Honda or a Maytag refrigerator, finding the vendor who will sell it to you for less is straightforward and the Internet actually makes it easy. When you're trying to decide on a product, between a Ford or a Honda, not so much. Doctors don't come off the same assembly line, every one of them is an individual "brand." Free market price pressures don't really apply.

But as you said, you still have to shop around. If you think you have an ear infection and just need some antibiotics, then most people will be happy to accept a cheaper doctor or nurse practitioner. If you want the best doctor you are most likely to go with who they affiliated with - Mount Sinai vs. some sole practitioner in Queens, nothing is different with our without a third party payer

[RebLem]

You and others speak of "shopping around" for health care services as though there were nothing to it. But there's much more to it than the doctor's fee: the doctor's reputation, his/her hospital affiliation, the convenience of his/her location, and more. Choosing a primary care physician from my Medicare Advantage's roster was complicated enough without additionally having to find out what each of the doctors charges for which services and weighing that against the other factors. I'm grateful that my Medicare coverage didn't require me to decide between the better doctor and the cheaper doctor.

The free marketeers always assume that shopping around for goods and services is a panacea. Where you've decided on a product like a Honda or a Maytag refrigerator, finding the vendor who will sell it to you for less is straightforward and the Internet actually makes it easy. When you're trying to decide on a product, between a Ford or a Honda, not so much. Doctors don't come off the same assembly line, every one of them is an individual "brand." Free market price pressures don't really apply.

But as you said, you still have to shop around. If you think you have an ear infection and just need some antibiotics, then most people will be happy to accept a cheaper doctor or nurse practitioner. If you want the best doctor you are most likely to go with who they affiliated with - Mount Sinai vs. some sole practitioner in Queens, nothing is different with our without a third party payer

Steve, you say you live in Texas, which automatically distorts the perceptions of even the sanest people, but you must be living on another planet entirely. If someone in your household is having a heart attack, and you call 911, are you going to go online while they are on their way and decide what hospital you want them to go to? Even if there is another person there to attend to the patient's needs while you calmly surf the internet, you will discover when the ambulance arrives that THEY decide where the patient is going and precious YOU have no choice WHATSOEVER.

Even Chalkie, who can probably afford any sort of medical treatment he wants anywhere for himself and his wife, found when his wife was ill and hospitalized in Florida that the hospital she was in transferred her to another hospital after she had achieved a certain level of recovery and that he had no choice as to where she went. He could arrange to have her transferred out of the new hospital to a treatment facility of his choice, but he had no choice as to where they sent her in the first place.

And ANY general or family practitioner or anyone familiar with best practices in medicine is going to roll his/her eyes at your suggestion that people should get routine care one place and go somewhere else for more advanced care. What you are supposed to do is pick a primary care physician who then acts as a gatekeeper, who helps you access specialists when you need them. And most insurance companies limit the selection of specialists they will let you go to. I used to go to the only board certified dermatologist practicing in New Mexico for my dermatological care. I can no longer do so, however, because Cigna, which the State of Illinois has chosen as my insurance carrier--I had no choice in that, either, and neither do most people--has decided that the dermatologist I was going to is now out of their network.

You apparently live in an ideology centered rather than a fact centered universe. You think capitalism offers perfect freedom for all and that only government is oppressive. Nothing could be further from the truth, as can be seen by the number of Republicans in Congress who rail against "government controlled health care" in the morning and then check into Bethesda Naval Hospital for their own care in the afternoon.

[BWV 1080]

Wow losing track of all the straw men there Reb. Of course people choose all the time to trade off lower quality care for convenience. If you have a sinus infection you are not going to insist that nothing but John Hopkins will do. We accept all sorts of trade offs between quality of service and price, both in medicine and in another services. The airline industry is a good model- regulation guarantees some minimum level of safety but consumers are free to choose between paying a fortune for first class or paying less for coach (in fact the prices paid by first class subsidize the coach passengers - a little bit of wealth redistribution going on there). Airline safety has improved dramatically since deregulation and the cost of flying is a fraction of what it was in the 70s. Government control of healthcare will of course force consumers to accept lower quality. If you fix the price of something then by necessity you have to ration it. Many of the best doctors already do not accept Medicare, and the program in its current form cannot possibly continue - it already is heavily subsidized by the rest of the healthcare industry. Most of the healthcare dollars spent do not involve urgent life or death issues, rather it is the maintenance of chronic conditions. There is all sorts of room for markets to figure out, within sound medical limits, what trade offs of cost and convenience consumers are willing to accept for their healthcare services. Medicine is the most important and complex service that any of us receive, it boggles the mind to thing that a top down approach dictated by panels controlled by self-interested providers will create an optimal outcome.

[RebLem]

Government control of healthcare will of course force consumers to accept lower quality. If you fix the price of something then by necessity you have to ration it.

If you lived in a fact based universe, you would know that so-called "free markets" also ration care by making many people ineligible, and by pricing care out of the reach of many.

Many of the best doctors already do not accept Medicare

,
As I am sure you know, even fewer doctors accept Medicaid. Why? Because it is a means-tested program, and reimbursement rates are consequently lower for Medicaid patients that for Medicare patients. So what is the solution right-wingers propose for the fact that some doctors, who would rather treat only their private pay friends from the country club, don't want to mix with ordinary working people? Means testing, which is bound to make the problem worse.

and the program in its current form cannot possibly continue - it already is heavily subsidized by the rest of the healthcare industry.

That's exactly the way insurance companies work, too. They present hopsitals with a captive population of policy holders they can promise to the hospitals and they say, "Now, in return for this guaranteed income stream, we want you to give us favorable rates, which do not include a factor for the costs you run up treating indigent patients. Let your local county or state taxpayers pay for that. Also, really soak the wealthy private pay patients."

Most of the healthcare dollars spent do not involve urgent life or death issues, rather it is the maintenance of chronic conditions. There is all sorts of room for markets to figure out, within sound medical limits, what trade offs of cost and convenience consumers are willing to accept for their healthcare services. Medicine is the most important and complex service that any of us receive, it boggles the mind to thing that a top down approach dictated by panels controlled by self-interested providers will create an optimal outcome.

Other countries manage to do it, BWV 1080, at far less cost than we pay. Are you saying Americans are the dumbest people on Earth and we alone can't manage it?

[BWV 1080]

You are conflating a couple of issues in your histrionic ranting.

If you lived in a fact based universe, you would know that so-called "free markets" also ration care by making many people ineligible, and by pricing care out of the reach of many.

the question of the assistance that should be given those unable to afford healthcare is independent of the degree to which markets are allowed to function in the healthcare industry.

So what is the solution right-wingers propose for the fact that some doctors, who would rather treat only their private pay friends from the country club, don't want to mix with ordinary working people? Means testing, which is bound to make the problem worse.

<irrelevant paranoid ad hominem rant>

Other countries manage to do it, BWV 1080, at far less cost than we pay. Are you saying Americans are the dumbest people on Earth and we alone can't manage it?

other countries have single payer systems - which I am sure you are aware that the ACA is not. ACA is healthcare corporatism, not healthcare socialism and I am afraid it will perpetuate our current "worst of both worlds" system. Single payer systems lower costs by rationing and studies show that Europeans and Canadians tend to consume far less healthcare services, for better or worse, than Americans.

I agree with your point about the current system - my whole argument is against third party payment for basic healthcare services and for finding ways to incent consumers to consider prices and supplier to reduce costs = , whether in tradeoffs in convenience for non-urgent, non-life threatening conditions, not automatically taking the latest on-patent drug compared to the generic that works just as well, etc. The other part is making providers more efficient, which again there is no real incentives for either under the current system or the ACA. Obama and the dems had to payoff the healthcare and pharma industries to get the ACA passed, and now we will live with a system that has simply further entrenched the private interests responsible for our current mess ( http://www.nytimes.com/2012/06/09/us/po ... d=all&_r=0 )

[RebLem]

It is very convenient and a very cheap trick to characterize every statement you really don't have an answer for as a "rant."

Not all other countries have single payer systems, though the most cost effective ones do. The health care system in Switzerland, however, depends entirely on a highly regulated private health insurance industry, and the ones in Germany and Holland mostly do. In addition, Medicare is a single payer system here in the USA and so is the VA system. And, as I say, a good many Republicans choose government health care over the private alternative when they are lucky enough to have a chance.

[John F]

But as you said, you still have to shop around. If you think you have an ear infection and just need some antibiotics, then most people will be happy to accept a cheaper doctor or nurse practitioner. If you want the best doctor you are most likely to go with who they affiliated with - Mount Sinai vs. some sole practitioner in Queens, nothing is different with our without a third party payer

Choosing the best doctor for my personal situation, when the cost to me is not a factor, is not what I'd call "shopping around." And hospital affiliation is not a luxury - it has to do with the quality of specialists my personal care physician will recommend for me when my needs go beyond getting a flu shot.

Continuing with the real world example of myself, my Medicare Advantage company has a network of pcp's and specialists to choose from, which narrows my choices of course but also provides information about the doctors I can choose among and assures a certain level of competence and service, making the choice easier. I found one whose office is not far from me, whose specialty is cardiology which is relevant to my needs, and whose hospital affiliations are with nearby Long Island College Hospital and also New York Presbyterian Hospital, some say the best in the city. Without insurance coverage of my routine visits, I might not be able to afford him, but I can afford the $15 co-payment per visit under Medicare, which of course is health insurance.

I also take three prescription drugs, nothing dramatic, for a co-payment of about 10¢ a pill - their uninsured retail cost is a good deal more. This is preventive, the conditions they are for aren't life-threatening now, but untreated they could land me in hospital - or on a slab.

So when you airily say that people should pay out of pocket for "routine health care," and insurance shouldn't cover it, I think you don't grasp the implications for real people in the real world. Such as me.

[lennygoran]

Other countries manage to do it, BWV 1080, at far less cost than we pay. Are you saying Americans are the dumbest people on Earth and we alone can't manage it?

As I've mentioned before this show is quite an eye opener and I highly recommend watching it!

Sick Around the World

http://www.pbs.org/wgbh/pages/frontline ... dtheworld/

Regards, Len

[RebLem]

Other countries manage to do it, BWV 1080, at far less cost than we pay. Are you saying Americans are the dumbest people on Earth and we alone can't manage it?

As I've mentioned before this show is quite an eye opener and I highly recommend watching it!

Sick Around the World

http://www.pbs.org/wgbh/pages/frontline ... dtheworld/

Regards, Len

Len, BWV 1080 has enough trouble learning for Americans outside of Texas. He ain't gonna pay any attention at all to furryners.

[lennygoran]

Len, BWV 1080 has enough trouble learning for Americans outside of Texas. He ain't gonna pay any attention at all to furryners.

This made me think about someone I had just about forgotten!

Rick Perry To 6.5 Million Texans With No Healthcare-You're On Your Own

http://www.forbes.com/sites/rickungar/2 ... -your-own/

Regards, Len

[jbuck919]

Let's look at a couple of comparisons with food. It is true--as Steve says of health care--that everybody's basic food needs are the same. Although people indulge in luxury eating at different levels, no one ever has a food emergency or unpredictable event that requires an unexpected expense. If we only knew we needed a flu shot every year, we could budget for it as we do with food, but we have no idea what our medical needs may be from one day to the next, let alone over the whole year. To me, the idea that health insurance should not cover "ordinary" expenses sounds like a variation of the whining of people who haven't had an expensive health challenge yet because they have to pay into a pool that benefits those who ran out of luck before they did. (All this in addition to the wisdom of preventive health care as stated by John F.)

Now look at the comparison with food another way: If we did with food what Steve is suggesting we do with health care, we would seek out what was cheapest for every food item and visit multiple stores weekly to get the best deals on each. (As a matter of fact, that is what some people do, but it is neither practical nor desirable for the great majority of us.) Instead, we choose one or two stores to patronize regularly, just as we would choose one insurance provider and one HMO or whatever. To my mind, bringing the market to bear on health care does not mean constantly shopping around for the best deal, but rather precisely what the health care exchanges are designed to do, which is to allow comparison shopping for the best deal in insurance rather than individual services. Whether this will work in terms of meaningful differences in premiums for roughly equivalent levels of care remains to be seen, but I will point out that the free market in this case has been impeded by the elimination of the likely highly competitive public option.

[Teresa B]

As a physician now for over 30 years, let me just say, it's impossible to "shop around" for health care. That concept is almost total nonsense. How on earth is a prospective patient to find out the information necessary to determine whom/what to "buy"? Yep, you can look at state board websites to see if someone is licensed in good standing, and you can see their degrees, training, etc. But barring egregious incidents like punitive measures taken by state medical boards, or multiple malpractice losses/settlements, you will not find much to guide you in what medical provider to choose.

I guarantee, you won't find anything to direct you one way or another in my area toward a certain dermatologist. I can cite for you one who flunked the pathology section of the Derm board exam the first time, and that dermatologist is reading pathology slides. But you as a patient would never know you might be getting a suboptimal interpretation of your biopsy. And that dermatologist?--charges the same amount as the one down the street who is more competent in that area. Once you throw in factors like choice of hospitals, use of ancillary practitioners, bedside manner (yep, it makes a difference), wait time, charges, and myriad other items, just try to "shop around".

As for patients paying out of pocket for all routine care, with the current high deductibles they are essentially paying for everything up to $2 or 3 thousand in many cases; If there were no coverage for drugs, and everyone had to pay $500 for a tube of cream (yes), that boils down to rationing by virtue of inability to pay. And what would you consider to be "routine"? That needs to be addressed, and by whom? Insurance companies?--Would it be all outpatient services? In that case your "routine" basal cell carcinoma on your nose, which I have to excise in stages and repair with a complex procedure, will run you $1200-1500. A good chunk to pay up front--and many patients have more than one basal cell.

Single-payer such as Medicare for all, while it would clearly require a major tax increase, would obviate the need for the ever-higher premiums charged by insurance companies. Some rationing might occur, but we have rationing now in the guise of unaffordability. "Rationing" can be compassionate and intelligent when the right criteria are used, and the right people make the decisions.

Teresa

[John F]

I was hoping you'd chip in, Teresa. I'd add only that I wouldn't want to wait until a serious illness or accident before looking for the doctor or specialist I'd be entrusting my life to. I want that doctor to know me well when healthy, as a basis for working at getting me healthy again.

And it isn't just doctors that are impossible to "shop around" for. It can be medication too, as Frank Lalli found out. He's on Medicare, but it would be the same or worse if he wasn't and had to choose which health insurance to buy.


A Health Insurance Detective Story
By FRANK LALLI
Published: December 1, 2012

I’ve had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I’ve never faced a more confounding reporting challenge than the one I’m engaged in now: What will I pay next year for the pill that controls my blood cancer?

After making more than 70 phone calls to 16 organizations over the past few weeks, I’m still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?

The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.

Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.

But if a seasoned personal-finance journalist can’t get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?

A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don’t get reliable answers to straightforward questions...

http://www.nytimes.com/2012/12/02/opini ... story.html

[Teresa B]

John, I feel for your predicament! I hope you can get the issue resolved in an affordable way as soon as possible. And of course you are not the only person who has to face this sort of dilemma. My mother-in-law, a relatively healthy 92-year-old with a United HealthCare Medicare Advantage plan, recently became one of the (thousands of) pawns in a p*ssing contest between UHC and a hospital/doctor chain called "Baycare". These two giants were having a severe dispute about reimbursements, resulting in Baycare refusing to provide care for UHC patients. UHC "assured" my mother-in-law that they would continue to cover her at that provider through 2013; meanwhile Baycare providers sent a message saying, "Uh, yeah, but...we won't accept your UHC," so what was she to do? She asked me, and I honestly didn't know what to tell her, except to choose another insurance plan. So she chose an Aetna plan, which I hope will work for her. Luckily she is very sharp and can fairly well understand what is included in various plans. Imagine all the seniors and others who are not so aware.

With the combo of ever-increasing medical technology, Byzantine complexity and obscurity of information (as you encountered), shopping around is virtually impossible. Access to basic health care ought to be part of "life, liberty and the pursuit of happiness", and how wonderful it would be if Americans were free of the ongoing worry of losing health care benefits, or going bankrupt due to costs not covered.

Teresa

[John F]

Actually, I think I'm pretty well set up thanks to Medicare. But if it weren't for Medicare, yes, I'd be in a predicament - even if I didn't have cancer like Frank Lalli and have to buy expensive medication to stay alive.

[BWV 1080]

But this is a total canard, as everyone already has to shop around both for doctors and medicine. All doctors are not of comparable quality and most medication is a trial and error process, made more complicated by rent-seeking behavior of big pharma which continually introduces new very expensive drugs, most of which are simply minor chemical tweaks of existing, off-patent medication and no more effective. If you have an ear infection, you will go to a drop-in clinic to get some antibiotics, if you have cancer its a much different process.

[Teresa B]

But this is a total canard, as everyone already has to shop around both for doctors and medicine. All doctors are not of comparable quality and most medication is a trial and error process, made more complicated by rent-seeking behavior of big pharma which continually introduces new very expensive drugs, most of which are simply minor chemical tweaks of existing, off-patent medication and no more effective. If you have an ear infection, you will go to a drop-in clinic to get some antibiotics, if you have cancer its a much different process.

You're confusing "shopping around with the benefit of the data" (pretty clear-cut if you're looking for a Nook or a Kindle), with "shopping around without the data, hoping you buy a good value". Yes, we have to shop around, and we can get some idea of who might be a good choice in physicians, or what generic drug we might get for less. But the problem is, we are shopping with very little real information.

Your dichotomy of ear infections and cancer is a false one. In reality there is a continuum of "seriousness" and complexity when it comes to medicine and the various ills the flesh is heir to. Fine, you can get decent treatment for your ear infection at the local walk-in. What about that funny nagging abdominal discomfort you keep getting? It could be as simple as constipation, or it could be a little more complex--maybe gall stones; or it could be warnings of appendicitis; if you're female you should keep pelvic issues in mind, like ovarian cyst, endometriosis, or ectopic pregnancy; or, it might be colon or pancreatic cancer, or lymphoma.

Now you tell me, can you realistically "shop around" and determine exactly whom to choose as far as diagnostic capabilities, cost-effectiveness, ease of appointments, correct specialty, and so on? Not to mention, do you have the expertise to know exactly what testing you need? Could run anywhere from a simple physical exam and blood count, maybe an abdominal film or ultrasound--to CT scanning, MRI, GI series, endoscopy, exploratory laparoscopic surgery, and/or other expensive and invasive tests.

You are absolutely right that not all doctors are of comparable quality. But how do you, the patient, figure out which one is more likely to order more tests than you need, or which one is going to dismiss your symptoms, give you a laxative, and hope you don't show up in the ER with a ruptured appendix? (At which point all shopping around becomes irrelevant.)

[BWV 1080]

i agree, but this issue does not change with the degree to which markets are allowed to function in the healthcare industry.

[RebLem]

i agree, but this issue does not change with the degree to which markets are allowed to function in the healthcare industry.

Sheer gobbledegook. I just finished watching tonight's 60 Minutes. They presented a report on HMA--Hospital Management Corp--a company which runs and manages hospitals. They have a goal of 20% admissions for their emergency room physicians, regardless of conditions, and for people over 65 with medicare, its 50%. The sole goal is making money. They had several physicians plus a couple people from the central office testify to this, and the physicians were from widely separated sections of the country, demonstrating that this is a national policy, not a project of some out of control regional manager. Doctors who do not meet their goals are in trouble, often fired if they persist.

Another great argument for a single payer system.

[BWV 1080]

i agree, but this issue does not change with the degree to which markets are allowed to function in the healthcare industry.

Sheer gobbledegook. I just finished watching tonight's 60 Minutes. They presented a report on HMA--Hospital Management Corp--a company which runs and manages hospitals. They have a goal of 20% admissions for their emergency room physicians, regardless of conditions, and for people over 65 with medicare, its 50%. The sole goal is making money. They had several physicians plus a couple people from the central office testify to this, and the physicians were from widely separated sections of the country, demonstrating that this is a national policy, not a project of some out of control regional manager. Doctors who do not meet their goals are in trouble, often fired if they persist.

Another great argument for a single payer system.

again, another argument that one has to shop around healthcare providers

the best hospitals providers are private non-profits - and if they are run well enough there is no room for shareholder-owned for-profit organizations. HCA has a very small presence in Houston, which has about the best facilities in the country

[jbuck919]

i agree, but this issue does not change with the degree to which markets are allowed to function in the healthcare industry.

Sheer gobbledegook. I just finished watching tonight's 60 Minutes. They presented a report on HMA--Hospital Management Corp--a company which runs and manages hospitals. They have a goal of 20% admissions for their emergency room physicians, regardless of conditions, and for people over 65 with medicare, its 50%. The sole goal is making money. They had several physicians plus a couple people from the central office testify to this, and the physicians were from widely separated sections of the country, demonstrating that this is a national policy, not a project of some out of control regional manager. Doctors who do not meet their goals are in trouble, often fired if they persist.

Another great argument for a single payer system.

again, another argument that one has to shop around healthcare providers

the best hospitals providers are private non-profits - and if they are run well enough there is no room for shareholder-owned for-profit organizations. HCA has a very small presence in Houston, which has about the best facilities in the country

Excuse me, but how is the free market consistent with the best facilities being not-for-profit? And I have long been under the impression that the Baltimore-Washington area, where I once received extensive in-patient care at Johns Hopkins Hospital, then rated the best in the country if not the world, was at or near the top, with perhaps New York and Boston offering some slight competition. However, that is beside the point. Nobody doubts that the US is lousy with superlative medical "facilities," a glory of our civilization if only we could figure out how to finance the care of those who need them.

Nobody does realistically anything but this: You find a provider network of some sort, ask someone you know for the name of a good PCP (if you know someone who knows), and take it from there. That's how I found my PCP, who has been to hell and back with me and and can't take any new patients because he is in such demand. But if I hadn't been so lucky, I still would not have ended up with a "lemon." Board- and state-enforced quality standards for medical practice exclude anything but excellence. Or perhaps someone favors deregulation of medicine so that the quality of care can also be determined by pure competition.

[John F]

Quite so. I didn't "shop around" for my Medicare Advantage program. A friend who was already enrolled, described its benefits and the quality of the doctors and specialists in its network that she had consulted. She was an MD, though a shrink rather than a sawbones, and that was good enough for me - I signed up without looking into alternatives, or even having a clear idea of the difference between straight Medicare and Medicare Advantage except that the latter gave me more services for no more money. It's worked for me, and I doubt that I am competent to have researched and made a better decision on my own.

And if I'm not competent to "shop around" effectively for the best health insurance coverage, even in the simple and sheltered world of Medicare, why should those who are less educated and less fortunate than me be expected to sort out the tangle of American private health insurance options?

[Teresa B]

Quite so. I didn't "shop around" for my Medicare Advantage program. A friend who was already enrolled, described its benefits and the quality of the doctors and specialists in its network that she had consulted. She was an MD, though a shrink rather than a sawbones, and that was good enough for me - I signed up without looking into alternatives, or even having a clear idea of the difference between straight Medicare and Medicare Advantage except that the latter gave me more services for no more money. It's worked for me, and I doubt that I am competent to have researched and made a better decision on my own.

And if I'm not competent to "shop around" effectively for the best health insurance coverage, even in the simple and sheltered world of Medicare, why should those who are less educated and less fortunate than me be expected to sort out the tangle of American private health insurance options?

Exactly. And I can readily admit that as a physician I am no expert in shopping around either. I have more knowledge technically as far as certain procedures, and of course I have some "inside" information about different doctors and local hospitals--but by contrast, I would have no idea about a hospital chain that might pressure its doc to admit me with marginal cause just to increase revenue. And to boot, if I happen to live closest to that hospital and need sudden medical attention, I have little choice but to go to that ER. There are so many reasons comparative shopping does not work in this arena, for the life of me I don't know why the dogmatic "shop around" philosophy continues to be viable.

[John F]

It's only BWV1080 who has suggested shopping around for the cheapest doctors, hospitals, and other providers for "routine" health care, which he says health insurance shouldn't cover. (Yes, he does.) The ACA actually works against that by mandating health insurance for all; the insurers, not the patients, will actually be paying the bills, minus deductibles. Lacking a Medicare-like single payer system, people will have to shop around for the best health insurance deal instead.

Not that this will be easy or straightforward. The ACA also sets some standards for what insurers have to cover and can't refuse you for, but I see the choice of insurer and policy as still being a very complicated and confusing business, probably with lots of loopholes and gotchas in the small print that the ACA doesn't cover.

There are also supposed to be insurance exchanges to help people sort things out, but these don't yet exist, several states are refusing to set them up (in which case the Feds will), and I'm sure there will be variations among the various state- and federal-run exchanges.

What fun.