Congressman Admits ObamaCare a Platform for Single Payer

[Bern80]

I think there should be only one plan, similar to Medicare. You would not shop for health insurance but you would shop healthcare providers. The savings are there. With single payer, your premiums do not include the insurance company profits, which has averaged nearly 10%. Unlike a single payer system, the insurance companies offer a variety of plans, PPO, HMO, EPO, POS, PPS, etc. These plans are then modified with riders tailored to the group policy holder. The cost of claim processing and customer support is very high at 10% compared to CMS at 2%. Single payer also has no marketing costs, CEO bonuses, or reserve requirements. Unlike insurance companies, the big cost of handling enrollment and unenrollment of members is not there. Once you enroll for single payer, it’s for life. Also, healthcare is no longer a cost to businesses. I think there is easily a 20% reduction in premium plus savings for businesses and healthcare providers.

You can't bend rules of economics Flopper. You are removing the financial responsibility of paying for services from those receiving said services and shifting it to an organization (government) that doesn't really care what things cost. And you expect cost to go down and quality to go up? Government has more options for dealing with expenses than the private sector. They can go into perpetual debt and/or they can raise taxes. Because they have more options for dealing with expenses costs will go UP not down.

The reason why providers don’t know the amount of insurance reimbursement at time of service is there are so many different policies with different deductibles, different co-insurance, and different exclusions plus many patients have multiple policies. To determine reimbursement, a claim(s) has to be submitted. That’s why providers bill the patient after the service is rendered unless you have an HMO type policy. The patient typically pays only after they receive their explanation of benefits, which can take months. The whole process leads to slow pays and no pays, which drives up the providers cost. With a single payer system, the benefits are the same for everyone and everyone knows what those benefits are. The provider can collect the charges that are the patient responsible at the time of service.

But what if I don't want to pay what you're paying for. I may not need the same coverage you do. Yet you're admitting now that no one will have any choices. Again you can not be in such denial about basic principles of economics. Lack of choice and tighter government control over an industry has NEVER worked out well for the consumer.

 

[Bern80]

One can only hope but I highly doubt that's happening.

And your link is bunk.

Yes, one can only hope for higher costs of procedures, fewer resources, and fewer coverage options.

You realize that makes no sense, right? The United States has the most free-market healthcare system in the world and it also has the highest costs. That's not by chance.

True. Yet it remains amazingly far from free. Of all the 'free' markets in America, medicine is probably the least free of them. And that we're in the mess we're in as a result is not by chance.

 

[Flopper]

I think there should be only one plan, similar to Medicare. You would not shop for health insurance but you would shop healthcare providers. The savings are there. With single payer, your premiums do not include the insurance company profits, which has averaged nearly 10%. Unlike a single payer system, the insurance companies offer a variety of plans, PPO, HMO, EPO, POS, PPS, etc. These plans are then modified with riders tailored to the group policy holder. The cost of claim processing and customer support is very high at 10% compared to CMS at 2%. Single payer also has no marketing costs, CEO bonuses, or reserve requirements. Unlike insurance companies, the big cost of handling enrollment and unenrollment of members is not there. Once you enroll for single payer, it’s for life. Also, healthcare is no longer a cost to businesses. I think there is easily a 20% reduction in premium plus savings for businesses and healthcare providers.

You can't bend rules of economics Flopper. You are removing the financial responsibility of paying for services from those receiving said services and shifting it to an organization (government) that doesn't really care what things cost. And you expect cost to go down and quality to go up? Government has more options for dealing with expenses than the private sector. They can go into perpetual debt and/or they can raise taxes. Because they have more options for dealing with expenses costs will go UP not down.

The reason why providers don’t know the amount of insurance reimbursement at time of service is there are so many different policies with different deductibles, different co-insurance, and different exclusions plus many patients have multiple policies. To determine reimbursement, a claim(s) has to be submitted. That’s why providers bill the patient after the service is rendered unless you have an HMO type policy. The patient typically pays only after they receive their explanation of benefits, which can take months. The whole process leads to slow pays and no pays, which drives up the providers cost. With a single payer system, the benefits are the same for everyone and everyone knows what those benefits are. The provider can collect the charges that are the patient responsible at the time of service.

But what if I don't want to pay what you're paying for. I may not need the same coverage you do. Yet you're admitting now that no one will have any choices. Again you can not be in such denial about basic principles of economics. Lack of choice and tighter government control over an industry has NEVER worked out well for the consumer.

47% of our healthcare now is paid out of public funds. For those that have private health insurance, 60% are group plans offered by the employer. What this means is that for the vast majority of Americans, about 75% have little or no choice in their insurance. They are covered under Medicare, Medicaid, VA, or an employer sponsored plan.

Approximately 35% of the insurance policies sold in the US are some type of managed care in which the member is restricted to a network of healthcare providers created by the insurer. For these people a single payer plan would provide a much larger choice in healthcare providers.

I'm sure there are problems in a single payer system, but I don't think choice is one of them.

Government Funding Increases Healthcare Costs « The Enterprise Blog
HMOs and Managed Care

 

[Bern80]

47% of our healthcare now is paid out of public funds. For those that have private health insurance, 60% are group plans offered by the employer. What this means is that for the vast majority of Americans, about 75% have little or no choice in their insurance. They are covered under Medicare, Medicaid, VA, or an employer sponsored plan.

Approximately 35% of the insurance policies sold in the US are some type of managed care in which the member is restricted to a network of healthcare providers created by the insurer. For these people a single payer plan would provide a much larger choice in healthcare providers.

I'm sure there are problems in a single payer system, but I don't think choice is one of them.

Government Funding Increases Healthcare Costs « The Enterprise Blog
HMOs and Managed Care

Of course choice is a problem. In single payer there aren't any. And someone who doesn't understand economics and how competition and choice effect prices, might think lack of choice is a good thing. Believe me, I get how compelling and self servingly beneficial it is to say 'here you take my money and you handle it'. I hate to sound like a broken record but the fact is society is weakened the more you absolve the members of that society of responsibility.

 

[Flopper]

47% of our healthcare now is paid out of public funds. For those that have private health insurance, 60% are group plans offered by the employer. What this means is that for the vast majority of Americans, about 75% have little or no choice in their insurance. They are covered under Medicare, Medicaid, VA, or an employer sponsored plan.

Approximately 35% of the insurance policies sold in the US are some type of managed care in which the member is restricted to a network of healthcare providers created by the insurer. For these people a single payer plan would provide a much larger choice in healthcare providers.

I'm sure there are problems in a single payer system, but I don't think choice is one of them.

Government Funding Increases Healthcare Costs « The Enterprise Blog
HMOs and Managed Care

Of course choice is a problem. In single payer there aren't any. And someone who doesn't understand economics and how competition and choice effect prices, might think lack of choice is a good thing. Believe me, I get how compelling and self servingly beneficial it is to say 'here you take my money and you handle it'. I hate to sound like a broken record but the fact is society is weakened the more you absolve the members of that society of responsibility.

The vast majority of Americans can't choose their insurance carrier now. It's Medicare, Medicaid, VA, or an employer sponsored plan. If you are among the 35% that are in a managed care network, your choice of healthcare providers will increase with single payer since you won't be limited to the network.

 

[Bern80]

47% of our healthcare now is paid out of public funds. For those that have private health insurance, 60% are group plans offered by the employer. What this means is that for the vast majority of Americans, about 75% have little or no choice in their insurance. They are covered under Medicare, Medicaid, VA, or an employer sponsored plan.

Approximately 35% of the insurance policies sold in the US are some type of managed care in which the member is restricted to a network of healthcare providers created by the insurer. For these people a single payer plan would provide a much larger choice in healthcare providers.

I'm sure there are problems in a single payer system, but I don't think choice is one of them.

Government Funding Increases Healthcare Costs « The Enterprise Blog
HMOs and Managed Care

Of course choice is a problem. In single payer there aren't any. And someone who doesn't understand economics and how competition and choice effect prices, might think lack of choice is a good thing. Believe me, I get how compelling and self servingly beneficial it is to say 'here you take my money and you handle it'. I hate to sound like a broken record but the fact is society is weakened the more you absolve the members of that society of responsibility.

The vast majority of Americans can't choose their insurance carrier now. It's Medicare, Medicaid, VA, or an employer sponsored plan. If you are among the 35% that are in a managed care network, your choice of healthcare providers will increase with single payer since you won't be limited to the network.

You've basically said this a couple times now. I don't argue that it's true. I ask what's your point? Since there isn't a lot of choice now, it's okay if we just go ahead and make it so there's even less?

 

[Greenbeard]

Of course choice is a problem. In single payer there aren't any. And someone who doesn't understand economics and how competition and choice effect prices, might think lack of choice is a good thing.

There's an argument behind what you're making that's worth being made, but you're framing it entirely backwards. What you're arguing for here is less choice, not more.

For example, it seems fairly clear that your notion of choice centers mostly on the availability of less comprehensive insurance coverage that will cover fewer services in the event that you need access to them ("But what if I don't want to pay what you're paying for. I may not need the same coverage you do.") Which is, of course, the point Flopper is getting at: choice in the context of health care is generally inversely related to choice in health insurance.

Your (apparent) ideal of many competing insurance companies offering extremely (I would say "absurdly") customized insurance packages will only control costs if each insurer is associated with a particular, very limited or confined, provider network. Meaning the choice of insurance plans ultimately grants you access to a relatively small and specific set of providers (hospitals and doctors) and the heavy tailoring of the insurance package leads to a relatively small range of benefits being covered.

And that may be fine with you, but I tend think that for most people, choice is more important on the other end: in choosing a doctor, a health care facility, and an appropriate course of treatment. But that is exactly where your model limits choice.

What Flopper is pointing out is that most single-payer designs would work in the opposite direction: choice of the benefit package that the single payer will reimburse for is largely absent (though it will likely err on the side of generosity, with private supplemental insurance available for purchase if you so desire), but the choice of doctors and hospitals and treatment regimens increases substantially, since the concept of an "out-of-network" provider largely disappears. Competition for customers becomes focused where it should be: on the provider side.

Now, it's possible that your solution of limiting choice by restricting provider networks and funneling more people into very narrow benefit packages (i.e. trying to limit utilization by limiting access) is the best way to control costs. But I don't buy that. I don't see any particular reason why value-based insurance design principles--in which cost-sharing for the consumer is inversely related to the value of the service they seek--couldn't be incorporated into a single-payer system, and value-based purchasing--in which reimbursements to the payer are linked to quality measures--is already being instituted in a preliminary way by our current imitation of a single-payer, CMS.

 

[Bern80]

For example, it seems fairly clear that your notion of choice centers mostly on the availability of less comprehensive insurance coverage that will cover fewer services in the event that you need access to them ("But what if I don't want to pay what you're paying for. I may not need the same coverage you do.") Which is, of course, the point Flopper is getting at: choice in the context of health care is generally inversely related to choice in health insurance.

Your (apparent) ideal of many competing insurance companies offering extremely (I would say "absurdly") customized insurance packages will only control costs if each insurer is associated with a particular, very limited or confined, provider network. Meaning the choice of insurance plans ultimately grants you access to a relatively small and specific set of providers (hospitals and doctors) and the heavy tailoring of the insurance package leads to a relatively small range of benefits being covered.

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly. Flopper says he thinks costs would reduced by 20% under single payer. But isn't he really saying costs would be reduced by 20% by simply not having to deal with insurance companies? Would you be more inclined to pay directly for a service if it cost 20% less?

And that may be fine with you, but I tend think that for most people, choice is more important on the other end: in choosing a doctor, a health care facility, and an appropriate course of treatment. But that is exactly where your model limits choice.

But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

 

[Trajan]

I like the sound of that. Thanks for posting!

You are truly naive to believe things will actually get better under a single payer system. Especially when that single payer is the government.

Cause the government doesn't do anything right, I know I've heard it all before.

and apparently its hasn't soaked in.

 

[Trajan]

We should just set up two classes of hospitals

One for the rich, the other for everyone else

We're getting close to that now.

and????

maybe we should just fulfill the progressive wish and give 90% of the people shitty access and care so as to even out the playing field for the 20% NOW who have shitty access and care, would that give you comfort?

 

[Trajan]

So how exactly are the providers going to collect the same amount of money as before if the cost to people and employers is supposed to go down.

This is the question you believe any reform proposal should answer? How we can we find ways to keep spending the exact same amount of money, year after year?

It's not hard to predict the effect of your brand of "reform" on the average person's wallet.

[ame=http://www.youtube.com/watch?v=lSPNQ82Sq4E&feature=related]Prediction[/ame]

The reality is that we need to slow the growth rate of spending by improving value (roughly understood as the quality we get for a given level of expenditures) in the health care system. And we've got a long road ahead of us on that one. But if your goal is simply to protect providers' share of a certain percentage of GDP, you've already lost.

Government will either have to subsidize it to make up the difference and add to the debt as a result or it will have to raise taxes on everyone to cover the costs. This will also allow providers to actually raise the price of what they charge for services.

That is what happens when you subsidize something. When you set a price for a service one factor in doing so is knowing what people will pay and obviously I can charge more to whom money is less of a factor, in this case government.

I'm not familiar with any single-payer proposals that involve providers retaining the tremendous power they currently have over prices. In fact, that's generally one of the primary arguments offered in favor of single payer proposals. At present, prices (i.e. reimbursement rates) are dictated by provider market power relative to payers; different payers will often be charged different reimbursement rates for a single service based on how much of the insurance market they have cornered. That isn't the case, at least with hospitals, in the only state that currently has all-payer rate-setting (i.e. common reimbursements for all payers set by the state); and in that state, they're not bent quite as far over the barrel by hospitals:

On average, Maryland hospitals charged patients 20% above the cost to treat them in 2007, compared with a national average of 182%, according to the American Hospital Association.​

If you're going to have a bilateral oligopoly, there are advantages to at least have a public entity refereeing; single-payer takes the concept further to pursue some other benefits beyond simply shifting the power to set prices away from providers.

getting fully back to the topic GB, remember those questions I asked you several months ago that you refused to answer? you should revisit them, you'd be surprised, not pleasantly. That's probably why you didn't answer them but I digress.

one of the questions went something like this - do you think the gov. has been honest as to its explanations of Obama care, managing expectations, giving it to us straight etc.

The OP speaks directly to this, its not a secret and never really has been that the goal was to push this, or better said, laying the ground work somehow some way to get us to single payer.

Every time we see another one of these moments where they slip and tell the truth, people do notice, this goes a along way as to damage Obamacare.

Good bad or indifferent , when one says they are doing one thing, while meaning to do another surreptitiously, well? This goes along way to building an maintaining the angst people feel about the program and it always will.

Then you have the prgms inside obamacare blowing up; waivers for 100 entities, a entire state to boot, ( and NY asking) to the complete re-write of long term care, the Sibelius confession after ALLLLLLLLLLLL of that denial as to using the funds twice, right now you could have the greatest product since sliced bread but guess what? Doesn't matter.

You are your own worst enemies because you never played it straight, not once from the day you dropped single payer. You didn't want to take no for an answer, so you went ahead and rammed a template for it down the countries throat and wonder why they don't buy it.

IF you didn't, you would have compromised and gotten 15-20 reps. from the senate and 50-75 in the house and we would not be here.

 

[Flopper]

For example, it seems fairly clear that your notion of choice centers mostly on the availability of less comprehensive insurance coverage that will cover fewer services in the event that you need access to them ("But what if I don't want to pay what you're paying for. I may not need the same coverage you do.") Which is, of course, the point Flopper is getting at: choice in the context of health care is generally inversely related to choice in health insurance.

Your (apparent) ideal of many competing insurance companies offering extremely (I would say "absurdly") customized insurance packages will only control costs if each insurer is associated with a particular, very limited or confined, provider network. Meaning the choice of insurance plans ultimately grants you access to a relatively small and specific set of providers (hospitals and doctors) and the heavy tailoring of the insurance package leads to a relatively small range of benefits being covered.

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly. Flopper says he thinks costs would reduced by 20% under single payer. But isn't he really saying costs would be reduced by 20% by simply not having to deal with insurance companies? Would you be more inclined to pay directly for a service if it cost 20% less?

And that may be fine with you, but I tend think that for most people, choice is more important on the other end: in choosing a doctor, a health care facility, and an appropriate course of treatment. But that is exactly where your model limits choice.

But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

For the insurance company, the network, whose purpose is to limit a patient's choice of providers is a given. From the time the first HMO was introduced, insurance companies have been pushing managed care. Why? Because the insurance companies see that limiting the patient’s choice is the way to control the cost of healthcare and maximize their profits.

The company contracts with those providers that will provide services at the least cost. Once contracted, doctors that do too many referrals to specialist or schedule too many tests or too many expensive procedures in the opinion of the company find their contract cancelled or renewed at a lower rate. Does this reduce cost. You bet it does. Does this provide the best quality care? No. It does just the opposite of what you advocate. It takes the responsibility away from patient and turns it over the insurance company.

 

[Bern80]

For example, it seems fairly clear that your notion of choice centers mostly on the availability of less comprehensive insurance coverage that will cover fewer services in the event that you need access to them ("But what if I don't want to pay what you're paying for. I may not need the same coverage you do.") Which is, of course, the point Flopper is getting at: choice in the context of health care is generally inversely related to choice in health insurance.

Your (apparent) ideal of many competing insurance companies offering extremely (I would say "absurdly") customized insurance packages will only control costs if each insurer is associated with a particular, very limited or confined, provider network. Meaning the choice of insurance plans ultimately grants you access to a relatively small and specific set of providers (hospitals and doctors) and the heavy tailoring of the insurance package leads to a relatively small range of benefits being covered.

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly. Flopper says he thinks costs would reduced by 20% under single payer. But isn't he really saying costs would be reduced by 20% by simply not having to deal with insurance companies? Would you be more inclined to pay directly for a service if it cost 20% less?

And that may be fine with you, but I tend think that for most people, choice is more important on the other end: in choosing a doctor, a health care facility, and an appropriate course of treatment. But that is exactly where your model limits choice.

But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

For the insurance company, the network, whose purpose is to limit a patient's choice of providers is a given. From the time the first HMO was introduced, insurance companies have been pushing managed care. Why? Because the insurance companies see that limiting the patient’s choice is the way to control the cost of healthcare and maximize their profits.

The company contracts with those providers that will provide services at the least cost. Once contracted, doctors that do too many referrals to specialist or schedule too many tests or too many expensive procedures in the opinion of the company find their contract cancelled or renewed at a lower rate. Does this reduce cost. You bet it does. Does this provide the best quality care? No. It does just the opposite of what you advocate. It takes the responsibility away from patient and turns it over the insurance company.

Then you're not listening to what I'm advocating, cause this will be the third time I've state it; and that is to minimize the roll of private insurance. To make paying directly for services more affordable and more appealing than purchasing an insurance plan.

 

[Greenbeard]

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly.

I'm not sure how you figure that. I don't know how large a deductible you're suggesting/imagining become the norm, but it seems very likely that what you're suggesting would expand the average hospital business office, not contract it, as more people pay like some of the uninsured do today: by setting up a payment plan. If you want to replace showing an insurance card with encouraging providers to run credit checks on everyone who walks in the door, you're going to see increases in this.

That said, that line of thinking tends to ignore the actual distribution of health care spending in the U.S. Spending is extremely concentrated: if the least expensive half of the population disappeared from the face of the earth tomorrow, it wouldn't even make a dent in our national spending on health:

The notion that the most expensive slice of the population simply doesn't have enough skin in the game--that they aren't feeling the financial pinch of the health services they're consuming--is also not borne out by the facts:

Out-of-pocket costs can impose a significant financial burden on individuals and families. These expenses include deductibles, copayments, and payments for services that are not covered by health insurance. Over half the people in the top 5 percent of all health care spenders had out-of-pocket expenses (not including out-of-pocket health insurance premiums) over 10 percent of family income. More specifically:

• Thirty-four percent had out-of-pocket medical expenses that exceeded 10 percent of family income.
• Eighteen percent had out-of-pocket expenses in excess of 20 percent of family income.

Attempting to slow spending by indiscriminately in shifting more costs to patients in the form of higher out-of-pocket spending isn't likely to do much good for those chronically ill, most expensive folks. In fact, the entire consumer-directed care concept has dubious effects on patient and population health because it achieves savings through indiscriminate reductions or deferments in care--when I say "indiscriminate" I mean that there's little evidence that distinctions between necessary and unnecessary care are made. If your interest is only in costs, then that may work fine for you; if, on the other hand, you're also interested in health--particularly in not harming health outcomes--then that should give you pause.

And then there are the even broader issues that likely get neglected in what you're suggesting, like the need for better care coordination or the ongoing struggle to shift from buying health widgets (i.e. Procedure X) and toward buying health outcomes. And there's the simple fact that health markets don't quite look like others, no matter how hard you squint: culturally, the full shift from patient to consumer and from physician-as-agent to physician-as-salesman will be difficult, and potentially damaging to the care process; health care delivery is dominated by large institutions that often have significant market share in an area, not a nice symmetric many-buyers-and-many-sellers setup; and we don't yet have in place the infrastructure that would make smart shopping possible (though on this point I'm hopeful that we've begun the process of changing that), such as rigorous public quality reporting on process, patient experience, and health outcomes and widespread, easy access to the best data on the comparative effectiveness of various treatment options.

But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

The concept of a network doesn't spring from the coverage decision you make in selecting a particular plan, it arises from the agreements your insurer has in place with health care providers. When you have your "catastrophic" event in your proposal, some insurer will be picking up most of the tab. And they may well have certain specific facilities that they funnel you to because of their business relationship with them.

 

[boedicca]

IOW, people who have more resources use them to acquire the things they need. People without money spend less.

Duh.

 

[Flopper]

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly. Flopper says he thinks costs would reduced by 20% under single payer. But isn't he really saying costs would be reduced by 20% by simply not having to deal with insurance companies? Would you be more inclined to pay directly for a service if it cost 20% less?



But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

For the insurance company, the network, whose purpose is to limit a patient's choice of providers is a given. From the time the first HMO was introduced, insurance companies have been pushing managed care. Why? Because the insurance companies see that limiting the patient’s choice is the way to control the cost of healthcare and maximize their profits.

The company contracts with those providers that will provide services at the least cost. Once contracted, doctors that do too many referrals to specialist or schedule too many tests or too many expensive procedures in the opinion of the company find their contract cancelled or renewed at a lower rate. Does this reduce cost. You bet it does. Does this provide the best quality care? No. It does just the opposite of what you advocate. It takes the responsibility away from patient and turns it over the insurance company.

Then you're not listening to what I'm advocating, cause this will be the third time I've state it; and that is to minimize the roll of private insurance. To make paying directly for services more affordable and more appealing than purchasing an insurance plan.

I hear you. I assume you're talking about using insurance with a high deductible. The use of catastrophic insurance will reduce premiums, but will it really reduce the overall cost of healthcare? If I have to pay the first $5,000 each year of my healthcare cost, I certainly will not be running to the doctor every time I have a little ache or pain. But it also encourages me to save money by delaying treatment and diagnosis of minor problems which may become major problems, yearly checkups, and preventive care. We know most our healthcare dollars do not go to routine care. It's the serious illnesses and end of life care that is responsible for most of our healthcare costs.

 

[Flopper]

No, that's not my vision at all. My vision is to address the cost of services so that insurance is only used for the most catastrophic of issues. The same cost reducing notion of stuff providers would no longer have to deal with as far as insurance companies go under single payer would also apply if people were to pay directly.

I'm not sure how you figure that. I don't know how large a deductible you're suggesting/imagining become the norm, but it seems very likely that what you're suggesting would expand the average hospital business office, not contract it, as more people pay like some of the uninsured do today: by setting up a payment plan. If you want to replace showing an insurance card with encouraging providers to run credit checks on everyone who walks in the door, you're going to see increases in this.

That said, that line of thinking tends to ignore the actual distribution of health care spending in the U.S. Spending is extremely concentrated: if the least expensive half of the population disappeared from the face of the earth tomorrow, it wouldn't even make a dent in our national spending on health:

The notion that the most expensive slice of the population simply doesn't have enough skin in the game--that they aren't feeling the financial pinch of the health services they're consuming--is also not borne out by the facts:

Out-of-pocket costs can impose a significant financial burden on individuals and families. These expenses include deductibles, copayments, and payments for services that are not covered by health insurance. Over half the people in the top 5 percent of all health care spenders had out-of-pocket expenses (not including out-of-pocket health insurance premiums) over 10 percent of family income. More specifically:

• Thirty-four percent had out-of-pocket medical expenses that exceeded 10 percent of family income.
• Eighteen percent had out-of-pocket expenses in excess of 20 percent of family income.

Attempting to slow spending by indiscriminately in shifting more costs to patients in the form of higher out-of-pocket spending isn't likely to do much good for those chronically ill, most expensive folks. In fact, the entire consumer-directed care concept has dubious effects on patient and population health because it achieves savings through indiscriminate reductions or deferments in care--when I say "indiscriminate" I mean that there's little evidence that distinctions between necessary and unnecessary care are made. If your interest is only in costs, then that may work fine for you; if, on the other hand, you're also interested in health--particularly in not harming health outcomes--then that should give you pause.

And then there are the even broader issues that likely get neglected in what you're suggesting, like the need for better care coordination or the ongoing struggle to shift from buying health widgets (i.e. Procedure X) and toward buying health outcomes. And there's the simple fact that health markets don't quite look like others, no matter how hard you squint: culturally, the full shift from patient to consumer and from physician-as-agent to physician-as-salesman will be difficult, and potentially damaging to the care process; health care delivery is dominated by large institutions that often have significant market share in an area, not a nice symmetric many-buyers-and-many-sellers setup; and we don't yet have in place the infrastructure that would make smart shopping possible (though on this point I'm hopeful that we've begun the process of changing that), such as rigorous public quality reporting on process, patient experience, and health outcomes and widespread, easy access to the best data on the comparative effectiveness of various treatment options.

But you're assuming the concept of the network as a given. If we're trying to remake the system then there aren't any rules per se. For example, instead of this idea that coverage be defined by this illness or that illness maybe we define it by cost. Regardless of what the condition is, if it costs less than x, it is the individuals responsibility. If it is more than x it will be all or substantially covered by insurance.

The concept of a network doesn't spring from the coverage decision you make in selecting a particular plan, it arises from the agreements your insurer has in place with health care providers. When you have your "catastrophic" event in your proposal, some insurer will be picking up most of the tab. And they may well have certain specific facilities that they funnel you to because of their business relationship with them.

I agree with your statement that there is not sufficient infrastructure to allow customers to shop for their healthcare. A recent study reported that less than 10% of the healthcare provider selection was based on customer cost or quality comparison. Customers select a provider based on referrals by a friend, or healthcare providers.

Cost comparisons are very difficult. Call a doctor and ask how much a given treatment will cost. The first thing you are likely to hear is that you will need an appointment with the doctor. Even then, you may have to have some tests. All this just to get a cost quote from one provider. A few years ago, my wife needed an MRI and it was going to be out pocket so I called three providers. Can you believe one told me they could not provide me that information? A second gave me the cost of several options which I did not understand and they referred me to the doctor. The third one never returned my call. Determining the quality can be every bit as difficulty. In my case, my wife was very ill and all I could think of was doing whatever it took to get her well as soon as possible. When a love one is very ill, shopping for the best price is not very high on the agenda. For these reasons, I don't see how healthcare consumers will ever be good shoppers.

 

[Bern80]

I'm not sure how you figure that. I don't know how large a deductible you're suggesting/imagining become the norm, but it seems very likely that what you're suggesting would expand the average hospital business office, not contract it, as more people pay like some of the uninsured do today: by setting up a payment plan. If you want to replace showing an insurance card with encouraging providers to run credit checks on everyone who walks in the door, you're going to see increases in this.

I think this reveals a bit about they way think things ought to be. Forget deductibles. What I'm talking about is, you break your arm, you go get it fixed, you pay the doctor for fixing your arm. Done. No dealing with co-pays, no deductibles, no insurance. Car mechanics don't run credit checks for people that need their cars fixed so I think you're making something out of nothing there.

The notion that the most expensive slice of the population simply doesn't have enough skin in the game--that they aren't feeling the financial pinch of the health services they're consuming--is also not borne out by the facts:

Out-of-pocket costs can impose a significant financial burden on individuals and families. These expenses include deductibles, copayments, and payments for services that are not covered by health insurance. Over half the people in the top 5 percent of all health care spenders had out-of-pocket expenses (not including out-of-pocket health insurance premiums) over 10 percent of family income. More specifically:

• Thirty-four percent had out-of-pocket medical expenses that exceeded 10 percent of family income.
• Eighteen percent had out-of-pocket expenses in excess of 20 percent of family income.

What's your point? Of course health care costs are burdensome. This is what I meant by you really think. And we can't solve this problem if you don't admit it. That problem is a lot of people, including you, want to treat the service of health care like it is different than any other service that someone may need. Paying for emergency car repairs is burdensome and expensive too. Does that mean I should expect that I don't have to pay my mechanic? Of course not. Maybe that's
where we need to start the conversation: Is a person morally obligated to pay for health care service they need? Is it that we should have to pay and it just costs too much? Or that it's just something to important for people to have to worry about financially? I'm really sensing it;s the later with some of you. If that's the case fine, just have the economic sense to understand that a system set up that way is going to be insulated from free market variables and thus costs are gonna be higher than what the free market would set.

Attempting to slow spending by indiscriminately in shifting more costs to patients in the form of higher out-of-pocket spending isn't likely to do much good for those chronically ill, most expensive folks. In fact, the entire consumer-directed care concept has dubious effects on patient and population health because it achieves savings through indiscriminate reductions or deferments in care--when I say "indiscriminate" I mean that there's little evidence that distinctions between necessary and unnecessary care are made. If your interest is only in costs, then that may work fine for you; if, on the other hand, you're also interested in health--particularly in not harming health outcomes--then that should give you pause.

That also defies basic economic logic. You think when costs more directly affect the consumer they don't figure out what a necessary expenditure and what isn't?

 

[Bern80]

For the insurance company, the network, whose purpose is to limit a patient's choice of providers is a given. From the time the first HMO was introduced, insurance companies have been pushing managed care. Why? Because the insurance companies see that limiting the patient’s choice is the way to control the cost of healthcare and maximize their profits.

The company contracts with those providers that will provide services at the least cost. Once contracted, doctors that do too many referrals to specialist or schedule too many tests or too many expensive procedures in the opinion of the company find their contract cancelled or renewed at a lower rate. Does this reduce cost. You bet it does. Does this provide the best quality care? No. It does just the opposite of what you advocate. It takes the responsibility away from patient and turns it over the insurance company.

Then you're not listening to what I'm advocating, cause this will be the third time I've state it; and that is to minimize the roll of private insurance. To make paying directly for services more affordable and more appealing than purchasing an insurance plan.

I hear you. I assume you're talking about using insurance with a high deductible. The use of catastrophic insurance will reduce premiums, but will it really reduce the overall cost of healthcare? If I have to pay the first $5,000 each year of my healthcare cost, I certainly will not be running to the doctor every time I have a little ache or pain. But it also encourages me to save money by delaying treatment and diagnosis of minor problems which may become major problems, yearly checkups, and preventive care. We know most our healthcare dollars do not go to routine care. It's the serious illnesses and end of life care that is responsible for most of our healthcare costs.

No. see above. I'm talking about not dealing with insurance companies period. And I suggest you consider the questions I asked above about who should be responsible for their health care costs. The only difference between caring for the human body and caring for one's car is that caring for the former is only slightly more important than your car. But the fact is, it's your life and your health. If you want both to be good, is it not YOUR responsibility first and foremost to take care of it? I just don't think either of you are being honest, because you keep complaining about how much it costs to take care of yourself. I ask why shouldn't it? It's the single most important thing in your life and yet you talk about it as if maintaining should not have to be your financial responsibility.

 

[Flopper]

Then you're not listening to what I'm advocating, cause this will be the third time I've state it; and that is to minimize the roll of private insurance. To make paying directly for services more affordable and more appealing than purchasing an insurance plan.

I hear you. I assume you're talking about using insurance with a high deductible. The use of catastrophic insurance will reduce premiums, but will it really reduce the overall cost of healthcare? If I have to pay the first $5,000 each year of my healthcare cost, I certainly will not be running to the doctor every time I have a little ache or pain. But it also encourages me to save money by delaying treatment and diagnosis of minor problems which may become major problems, yearly checkups, and preventive care. We know most our healthcare dollars do not go to routine care. It's the serious illnesses and end of life care that is responsible for most of our healthcare costs.

No. see above. I'm talking about not dealing with insurance companies period. And I suggest you consider the questions I asked above about who should be responsible for their health care costs. The only difference between caring for the human body and caring for one's car is that caring for the former is only slightly more important than your car. But the fact is, it's your life and your health. If you want both to be good, is it not YOUR responsibility first and foremost to take care of it? I just don't think either of you are being honest, because you keep complaining about how much it costs to take care of yourself. I ask why shouldn't it? It's the single most important thing in your life and yet you talk about it as if maintaining should not have to be your financial responsibility.

So you are saying no insurance at all, no catastrophic insurance. Who pays for the $100,000 hospital bill. I can put enough money away to replace my transmission or even replace the vehicle, but I can't save enough money to pay for an undefined medical cost that may or may not occur.

If you're talking about a single payer system that pays for large medical bills, I think that has merit. However, defining large is a problem.