TAUTOLOGY

The next phase in the coordinated campaign of anti-reform rhetoric in the health care debate apparently is to dip back into the Bush 2004 playbook and trot out the Red Herrings. I draw your attention to a recent editorial entitled "Fix the costs first." To wit:

The need for health reform is as plain as the headline on the front page of Tuesday's editions of The Buffalo News: "Salaried employees suffer loss of health care, reduced pensions due to Delphi bankruptcy." The system is falling apart. The wailing from the political right notwithstanding, without reform, we will have rationing.

But those on the left who continue to deny that controlling costs must be the first order of business need to read the same story. Today it's Delphi Corp. in Lockport, a company that is under severe economic strain. But as the costs of health care continue to soar — reaching 20 percent of gross domestic product by 2017 — more companies will find themselves under severe economic strain. Employer-based health care will become increasingly less available.

It's only a matter of time until we are besieged with warnings about capping malpractice claims.

Costs are not causing the problem, they are the end result of it. Drawing upon my experience in the world of medical collections – briefly, lest I start having flashbacks – the average hospital writes off tens of millions of dollars in services annually. That is to say lots of people are receiving services for which they don't pay. We know that emergency rooms are required by Federal law to treat any patient who presents himself regardless of ability to pay. For people without health insurance and with meager incomes, this becomes the sole source of medical care. Hospitals attempt to compensate for services they essentially provide for free by breaking it off in the ass of every patient with half-decent insurance. So the next guy through the door with a Blue Cross PPO gets charged $75 for an ibuprofen in an effort to make up the difference. Hospitals then pay insurers a discounted bulk rate for claims – thousands at a time – according an arcane formula that ends up being slightly more complicated than a group of astronauts doing their taxes in Latin. In short, they charge you $75 to get a negotiated payment of $60 from your insurance to start compensating for the fact that they just did a $15,000 operation to pull the steering column of a 1994 Toyota Tercel out of the sternum of an uninsured teenager.

The costs can't be controlled prior to extending coverage to everyone. The presence of 50 million uninsured people is in fact contributing mightily to the disconnect between the costs of medical care and reality. Bask in the rich irony as the Glenn Beck fan in the next cubicle wails loudly about how he isn't going to pay for anyone else's health insurance. We already pay for the uninsured. It's just a big, disorganized trainwreck, clearly superior to a government-administered program which would achieve the exact same end result.

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19 Responses to “TAUTOLOGY”

  1. jon Says:

    I really want to hear how much capping malpractice claims will reduce healthcare costs. Maybe a quid pro quo could be worked out: all malpractice claims will be capped, but health insurance companies have to reduce their premiums by 40% and can't discriminate against anyone for any health-related reason or dump any customers for reasons other than an inability to cover those premiums. I'm sure the companies will just jump at such a deal, since it's those malpractice claims that are driving 100% of the costs of healthcare, right?

    Yeah, and monkeys might emerge from my butt wearing Congressional lobbyist ID badges.

  2. j Says:

    I agree with jon–I want to see an analysis of the estimated costs/benefits of tort reform. From my understanding tort reform has been successful in Texas to keep down health care costs.

    (Admittedly my understanding is wholly based on economist articles, e.g. http://www.economist.com/specialreports/displaystory.cfm?story_id=13938907 and http://www.economist.com/world/unitedstates/displaystory.cfm?story_id=5307542)

    One main argument against tort reform is that it deters neglicence. From my (brief) clinical experience, if anything it causes doctors to devote more useless work and mental effort towards a whole new endeavor called "CYA activity"– cover your ass. This must be having a negative impact on the ability to treat patients cheaply, quickly, and effectively.

  3. Dominic Says:

    I think the idea re: capping malpractice claims is that the cost of malpractice insurance would then go down, lowering doctors' costs so that they could charge less for services. Of course this assumes that neither the malpractice insurers nor the doctors would just pocket the difference.

  4. grumpygradstudent Says:

    The price elasticity for the teenager of having the steering column pulled out of his chest is zero. The same is going to be true for many health procedures. People cannot go doctor shopping very easily when they are on the verge of death. When price is inelastic (due to a combination of the importance of the good for the consumer and the lack of substitutes for that good), prices will be inflated, and government needs to fix the market.

  5. Blakenator Says:

    Part of the savings could be gained through the tort system if you can calculate how much of the award is for future medical treatment, which would be included in the "system" if honest reform was accomplished. That would leave "pain and suffering" as the only cash payout option. The trial lawyers would not be amused.

  6. cyntax Says:

    Tort reform is more of a red herring than anything else:

    “It’s really just a distraction,” said Tom Baker, a professor at the University of Pennsylvania Law School and author of “The Medical Malpractice Myth.” “If you were to eliminate medical malpractice liability, even forgetting the negative consequences that would have for safety, accountability, and responsiveness, maybe we’d be talking about 1.5 percent of health care costs. So we’re not talking about real money. It’s small relative to the out-of-control cost of health care.”

  7. ladiesbane Says:

    Doctors themselves say overpricing and overutilization are key in some areas — the problems being the doctors, who order care and tests that are not really medically necessary, because they know insurance will pay:
    http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

    Medical insurance cannot be priced by a carrier at more than about 4% profit, and most carriers make significantly less. Rates are approved every year by the state DOI based on the prior year's costs, and data are gathered from provider reporting and public sources, not carrier records (at least in the states I've worked.)

    Turn the practice of medicine into a non-profit concern and see how many people go to med school the following year.

    Costs can be contained by limiting covered services — but tell people they can't have access to designer birth control pills and experimental surgeries with low success rates, and hear them scream about rationing.

    Costs can be contained by utilization review — but tell doctors who own physical therapy clinics that a sprained elbow doesn't need thirty weeks of PT and hear the laughter.

    Costs can be contained by preferred provider arrangements being extended to the uninsured, so that the guy on the street doesn't have to pay $10,000 for a carpal tunnel release that the hospital will only charge the carrier $6000 to perform.

    Or can we do away with PPO agreements altogether, and require prices be based on cost? The way the insurance carriers have to do it?

  8. Parrotlover77 Says:

    ladiesbane – My doctor, whom I know quite well, has told me on many occassions how hard it is to get an MRI. She doesn't diagnose them for no good reason. But it's pretty much standard practice to deny the request immediately and then she has to spend time writing a long letter and justifying the expense in appeal (time equals money). Meanwhile, the patient isn't magically getting any better…

    Limiting diagnostic procedures is exactly opposite of what we need to do. Unless the doctor operates their own diagnostic machines in-house (not many do), there is no incentive to ordering the procedure other than wanting to get to the bottom of the condition the patient is suffering.

    All that said, i'm not claiming there isn't insurance fraud going on where the procedures are ordered for the purpose of getting insurance money for no reason. But that's an entirely different problem than your family doctor trying to get your ass some bloodwork and an x-ray and repeatedly being turned down.

    Also, what's a designer birth control? I mean seriously. I've never heard of such a thing. Oh wait! It's women's health. That's always designer. We shouldn't cover that.

  9. ladiesbane Says:

    Parrotlover, you may not watch TV (I don't, much) but you may have seen ads for such products as Nuva-ring, Yaz, Yasmin, and other products. I refer to them as designer drugs because they were not created as improvements to the drugs, but as highly marketable profit-magnets.

    Yaz costs $50-$60/month and is not a meaningful improvement over good old ortho try-cyclen at $5/month. I started taking ortho-novum 777s in college, and the cost has not increased in twenty years — and I could afford it without insurance. A woman still made a little more than half what a man did at the same job, at that point, but women are now a major chunk of the market, and drug manufacturers are targeting us. You may want insurance companies to pay for Yaz in addition to generics, but I would rather the premium went elsewhere or went down.

    And I think that limiting ALL treatment, not just diagnostics, to what is medically appropriate, is key. I know the situations vary widely across the country in terms of provider agreements, but getting an MRI can be hard for a number of reasons — sometimes it's administrative/paperwork BS, or establishing medical necessity (and the irony of needing the MRI to diagnose and determine medical necessity in the first place.) I think diagnostics, of all things, should be easiest to allow, for exactly the reasons you say. But there are doctors who will, for fear of malpractice or love of money, order MRIs for mild headaches.

    The hardest part is people who have, for example, permanent back problems. The unrelenting pain makes them desperate, they will not believe there is no magic bullet, and if they hear of some new procedure that helped someone once somewhere, they want it — even if the AMA doesn't back it, even if most of the people who undertake it get worse. But how many individuals would need to have zero care that year in order to pay for one person's pointless $100,000 surgery? There are going to be unavoidable big-bill patients (ultra-preemies, end-stage renal, catastrophic accidents) — and loads of chronic patients (diabetes, cardiac, cancer, MS, etc.) — and their premiums aren't going to pay for a fraction of their care.

    I am for single-payor, and think gap coverage can be a fine compromise, but people who want designer drugs, maintenance chiropractic, in vitro fertilization, and other non-medically-necessary treatment, need to pay for it themselves.

  10. j Says:

    Let me first emphasize, with all appropriate respect to their dignified profession, FUCK TRIAL LAWYERS. We'd be better off not only without them, but also without their them.

    Also, to ladiesbane, I'd be happy to see how many med students enroll if health care were non-profit. Please get rid of all these self-entitled a-holes around my medical school. I guess I'm idealistic, but shouldn't the focus be on trying to heal people?

  11. ladiesbane Says:

    j, talking "shoulds" is important, but not always practical. There are already serious shortages of doctors in some areas. In New Mexico, for example, doctors in outlying areas charge far more than they do in ABQ or Santa Fe, because they can. Supply and demand.

    I'd prefer to be treated by the pure of heart, but like a lot of people who have had to wait hours at an emergency room, I would take any MD or DO who could give me nine stitches and some Keflex.

    Too, self-entitled assholes can still be skilled physicians, and good docs of true vocation can also be money-grubbing capitalists who voted for Bush every time.

  12. BillCinSD Says:

    http://www.cbo.gov/ftpdocs/55xx/doc5549/Report.pdf has a CBO report on the effect of tort reform legislation in the states up through about 2004

    and a more recent Canadian Medical Association study

    http://www.scnursinghomelaw.com/uploads/file/E4(1).pdf

  13. Chris Says:

    If the makers of this argument were truly interested in lowering costs, then they would argue for eliminating health insurance companies and instituting either government regulation or universal health care (with universal health care being more effective). I can't believe how many logical fallacies are used in the debate on health care. The cost "argument" is actually a red herring that is a cause and effect error: WOW!

    J, there's another word for idealistic: naive. How big is your school's endowment? How much money are your professors earning? How much do your possessions and needs cost? Healing people is only part of the equation in a capitalist society. There isn't a whole lot of idealism in putting food on the table, paying for kids, putting a roof over your head, etc. Believe me, your idealism will go right out the window when you exit college and start paying off hundreds of thousands of dollars in med school loans, get hungry, etc. The big idea is making health care affordable and reasonable, not "non-profit".

  14. Robert Says:

    I have a very good HMO (for a given value of 'very good'). I've managed to keep the same primary physician for over twenty years – it took some doing, but I've done it, and it helps. I have a chronic medical condition, disabling enough that I'm on SSDI, not so disabling that I can't take care of myself.
    The medication that is, not to put too fine a point on it, keeping me alive has a monthly retail cost of circa US$1700.00. I'm paying a $35.00 copay. My HMO would cut me off in half a heartbeat if there was any any ANY way to do it and not get sued to oblivion. I get a blood panel every four months so my M.D. can make sure the medication is still working. Again, my HMO would be tickled pink not to have to pay for that labwork.

    Conversely, a few years ago I got hit by a van while on my scooter. My HMO refused to pay for the ER visit for _six months_, apparently waiting for me to either give up or die. As I did neither, they eventually, grudgingly, paid up.
    So, I've seen both sides. And I'm one of the fortunate ones who _have_ coverage. Not sure if I have a pithy point to this, except that I really like being alive and hope to stay that way for a while.

  15. j Says:

    Chris, the magnitude of my admitted naievete is only surpassed by that of my "endowment"!

    I used the term non-profit because ladiesbane did. I agree that the high price of schooling is a problem, but it is not just a cause but also a result of expensive health care. Lower health care costs, and tuition will drop down too.

    I am finishing school debt-free thanks to busting my ass for research scholarships…that were funded by income taxes from the good people of the State of California. In return they got a scientific discovery of moderate importance. I don't believe one scholarship has ever been offered by an insurance company or health care provider.

  16. Chris Says:

    J: I will say you appear to be one of the good people in health care and care about making the world a better place. I'm personally glad you are going to be a health care professional and wish you well. I don't want to come across as anything other than wanting to debate points. Just two other things:

    I couldn't tell if you thought all lawyers were bad or not. Not every lawyer is a scumbag trial lawyer. James Madison, Thomas Jefferson, Honest Abe, and Gandhi were all lawyers, and many lawyers have bettered society through government and service. Many lawyers do pro bono work and are public interest lawyers. Many lawyers are also "idealistic". Somebody could just as easily say you are a scumbag doctor. It isn't really fair to do this.

    Also, tax money isn't as clean as you think it is, either. Insurance companies, whether health care or other, and health care providers are part of the good people of California that are taxed, and there's a good chance that money made its way to you.

  17. ladiesbane Says:

    P.S.: no matter how strange it may sound, I think we are pretty much all on one side here. Whether funded through reapportionment or a tax increase, I want all of us to have sufficient healthcare, with no fear or having to make desperate choices between food, rent, and meds. I am willing to pay extra to make it happen, as a matter of self-respect as much as practicality — we pay taxes for firefighters and public water; I think this is as important.

  18. Peggy Says:

    In defense of "Designer" birth control: I've been on three different kinds (ortho-tricylen lo, nuvaring, patch) and found all three to have wildly different results when interacting with my body. So far, the patch (arguably a drug designed for the lazy, who can't be bothered to take a pill every day) is by far the best. I'm happy that ladiesbane has been able to stick with her first form of BC without side effects like nausea, headaches, insane crankiness, depression, loss of libido, etc., but I wasn't. Yes, my main goal in taking birth control is to Not Get Pregnant, but I also like to have a reasonable quality of life while I do it. I pay more for my Rx than I would for (most varieties of) the pill, but I can afford to. What about lower-income women who can't afford BC that doesn't fuck them up? I don't think it's unreasonable to offer a variety of hormonal birth control methods to women for a low low price. Unwanted pregnancies are much more expensive.

    ANYWAY, I know that's a tangent. In general, I agree with posters here like ladiesbane who say that sufficient healthcare is a basic human right. I also think it should include mental health and reproductive health, because I work with a hell of a lot of fucked up teenagers (many of whom are pregnant/have been pregnant/will be pregnant unexpectedly). They need mental health care and good sex ed and reproductive healthcare, and them having these things would do much more than No Child Left Behind to help them get their asses through school and break the cycle of poverty.

  19. j Says:

    Hooray internet! *group hug*