Forum Thread

How to really decrease medical costs

rhornback 914 292 April 3, 2013 at 05:54 AM
Obamacare and the government's 'solutions' to medicine don't make any sense. They seek to increase revenue, decrease disbursements, but what about health care costs?

Obamacare seeks to expand the number of insured. But what effectively this means is people who are healthy (usually the young) subsidize the unhealthy and older people. How is this fair? If you are healthy, you pay more for the unhealthy? Young people, already overburdened by college debt and with limited job prospects are now going to get an additional 'tax' by requiring them to get health care? A tax which is not just on them but their employers. This tax decreases the likelihood that they will get a job.

On the other hand, the government wants to decrease medicare disbursements. OK, but how do the hospitals and doctor offices function? I guess it is up to the doctor's to figure out how to cut their own costs.

My solution is to decrease three of the primary drivers of health care costs.

1. Decrease the years of education to get a medical degree. As I have posted in the past, in other countries students go directly into medical school, they do not first get a bachelor degree.

2. Allow for more routine medical checks to be done by nurse practitioners. Most medical care is routine and doesn't require a full fledged doctor. Routine care should be done by nurse practitioners with a single doctor at the medical center, or who can refer patients to doctors for more complicated medical issues.

But you insist on seeing a doctor? Fine, but it should cost you more. The reimbursement by insurance and/or the government should be less.

3. Decrease medical liability. There needs to be a cap on medical liability. Yes I am sorry for those who have been injured, but regardless on whether we like it or not mistakes happen. A cap on medical judgments indexed to the consumer price index is needed to decrease the cost for the the doctor's and the hospitals liability insurance (which of course gets passed on to the patient).

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#2
For the most part your ideas are generally steps in the right direction.
#1 may be a hard sell but there is truth to the notion that medical school is a big burden and honestly it's hard to justify the cost and effort unless one is going into a high paying specialty. The GP pay isn't high enough to really justify the burden. Your proposal does lower the burden.
#2 is also quite reasonable and is actually happening. In some states there are perverse incentives against using NPs to do "MD" work. The doctors are willing to lobby to protect their own (NOTE: I am NOT anti-MD, I work with many and certainly see many things from their POV).
#3 this also would help, primarily in getting people to practice less defensive medicine. Defensive medicine probably costs us FAR more than any direct liability payouts (insurance + settlements).

In my opinion the real issue is the whole system was not designed to conserve costs. The means the costs are driven up in small and large ways all over the place. Think about what was needed to get the cost of a computer down from what it cost 20 years ago. 20 years ago you had to spend $1500 to get anything even remotely useable and perhaps $2500 to get "good but not great". A laptop was rather pathetic compared to the desktop and cost $3000+. Now you can get a laptop for $300 that can keep up with almost any basic task you might have. $1000 gets you a really nice laptop. So how did we get from 1993 to 2013? It wasn't based on any one advancement. A modern laptop has basically all the same parts as one from 1993 but we have figured out how to improve every one in may ways to both deliver more and cost less. Cars are another example of something that is delivering more in terms of adjusted cost than they did 20 years ago. Like computers it wasn't one breakthrough but squeezing bit by bit everywhere.

We need the same thing in healthcare. The big way you do that is reconnect the consumer and the buyer. Not easy to do but THAT would solve the problem over the long term. There would be winners and losers and some people would have inferior care but I think overall it would deliver more for less. But just as it was impossible to imagine how we could deliver a $300 laptop at a time when laptops cost $3000, it's hard for people to see how we could deliver care similar to today for say 1/3rd the cost.

I highly recommend this article for the insight it offers into what is wrong with the system and who aren't the bag guys. Really it was good reading all around.
http://www.theatlantic.com/magazi...er/307617/
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#3
Using nps and pas as doctors doesn't save money as they demand to be reimbursed the same as doctors.
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Quote from rhornback View Post :
My solution is to decrease three of the primary drivers of health care costs.

1. Decrease the years of education to get a medical degree. As I have posted in the past, in other countries students go directly into medical school, they do not first get a bachelor degree.

2. Allow for more routine medical checks to be done by nurse practitioners. Most medical care is routine and doesn't require a full fledged doctor. Routine care should be done by nurse practitioners with a single doctor at the medical center, or who can refer patients to doctors for more complicated medical issues.

But you insist on seeing a doctor? Fine, but it should cost you more. The reimbursement by insurance and/or the government should be less.

3. Decrease medical liability. There needs to be a cap on medical liability. Yes I am sorry for those who have been injured, but regardless on whether we like it or not mistakes happen. A cap on medical judgments indexed to the consumer price index is needed to decrease the cost for the the doctor's and the hospitals liability insurance (which of course gets passed on to the patient).
Nice thoughts. I also think you need to add

4. Upfront costs. All procedures and visit costs (for insurance and consumer) are explained upfront (no hidden expenses). I actually called my Dr once and said, "I'm worried I have a lung infection how much will an Xray cost?" Nobody could tell me. The answer was, well come in have it done, and we'll bill you. That would never fly at a body (auto) shop and shouldn't fly at a hospital or clinic.
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Quote from Halfspin View Post :
Nice thoughts. I also think you need to add

4. Upfront costs. All procedures and visit costs (for insurance and consumer) are explained upfront (no hidden expenses). I actually called my Dr once and said, "I'm worried I have a lung infection how much will an Xray cost?" Nobody could tell me. The answer was, well come in have it done, and we'll bill you. That would never fly at a body (auto) shop and shouldn't fly at a hospital or clinic.
One, unless you were paying cash the doctor isn't going to be able to guess exactly what your insurance will charge you. Second, chest xrays aren't big macs, you can't just roll up and order one.
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#6
#2 is a terrible idea for a number of reasons:

1) As our population is aging and becoming more obese, the disease burden is rising. At the same time, we have more opportunities than ever to prevent, treat or cure diseases. This means that medicine is dramatically different from from a generation ago - much more complex, and ultimately, far more difficult. At the same time, we're also seeing a steep rise in patient expectations about their care and more accountability from the payers (mostly medicare, but even private insurances). What this means that even the "simple" visits (which trust me, there aren't too many of these days) need to be used as opportunities for screening and prevention. Whether its obesity, smoking and other substances, sexual habits, etc.

For those with pre-established disease, this means that we need to be more aggressive with treatment and lifestyle modifications.

Doing all of this in 15-20 minutes is difficult for anyone, let alone an NP/PA, who typically has about 1/10 the number of hours in training (2 years of classes then straight to work as an NP, vs 4 rigorous years of medical school + a minimum of 3 years of residency working 70+ hours a week for a primary-care doctor). With less training comes less experience, less knowledge and ultimately, a reduced ability to manage complex cases efficiently, without referrals, and effectively. If most visits have several layers of complexity, then the model you're proposing becomes more inefficient rather than less.

2) As someone else alluded, you're assuming that PA's and NP's will be lining up at the door to do what you ask. The reality is that there's a large incentive for an NP or PA to enter higher paying specialty fields where they work less rigorously and get paid more. They didn't undergo 2 years of medical training to see colds and sore throats all day.

3) The "easier" visits are a necessary "breather" between the train-wrecks and complicated cases (of which I have 7-10 a day). Turning a physician's schedule into 20-30 highly complex and/or train-wrecks a day, spaced 20 minutes apart, will guarantee that you rapidly burn through your already dwindling primary care supply. Add to that the 2-3 hours of un-paid work at the end of the day coordinating referrals, reviewing and acting on labs, phone calls, etc. that would result when you see that many complicated patients each day, and you'd have a highly untenable situation.

4) The "hard" cases don't pay that much more than the simple ones. They take much longer. Ergo, you can't pack 20 complex cases for an MD in a day. But if the MD sees < 20 per day, he goes out of business because he's not bringing in enough money.

5) Patient continuity - there's a subtle, but well known correlation between patients seeing their own providers regularly, for routine and complicated stuff, and lower overall costs and higher satisfaction. Why? When one doctor sees you over years, he gets to know your personality, your "baseline". Its much easier for him to know when things aren't quite right, vs you're just having a bad day. I know that sounds strange, but I can't really describe it any better, and our own internal research shows significant cost reductions in tests and referrals when people see their own doc regularly.

For all of these reasons, Norther California Kaiser Permanente, which iz renound for its cost-efficiency and quality of care, phased out using NP's and PA's in their primary care clinics 6 years ago. They actually ended up costing more than hiring an MD, with poorer overall care. They are still used in specialty clinics with limited scopes (where the work is more "routine"). But overall, we're not talking about a substantial cost savings. Mind you, this is in a pre-paid model, where its not about how much you can bill the insurer, but how efficiently you can provide care, how much you can accomplish per visit, that effects the bottom line. And in that model, NP's and PA's just didn't work.
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Quote from Tony_Danza View Post :
One, unless you were paying cash the doctor isn't going to be able to guess exactly what your insurance will charge you. Second, chest xrays aren't big macs, you can't just roll up and order one.
1. I tried that route. "If I was paying cash how much?" still no number. I tried, "can you give me a ball park 100s or 1000s?" No answer.
Read "The Bitter Pill" in Newsweek.

2. Haha, I had mentioned my ailments to a Dr. friend of mine who said it was probably a good idea to get it check out and probably get some chest X-rays.
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#8
Pass a bill titled "Affordable Care Act"????
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Time to stop the war.....on businesses and individual success!

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Quote from Halfspin View Post :
Nice thoughts. I also think you need to add

4. Upfront costs. All procedures and visit costs (for insurance and consumer) are explained upfront (no hidden expenses). I actually called my Dr once and said, "I'm worried I have a lung infection how much will an Xray cost?" Nobody could tell me. The answer was, well come in have it done, and we'll bill you. That would never fly at a body (auto) shop and shouldn't fly at a hospital or clinic.
Shortly after Medicare came out in the 70s an article was published by a doctor talking about this sort of thing. To some degree you are right, we should be able to get a simple price on something that is the same every time. Other times it's not that simple. The article's example was a procedure that most of the time was very easy and straight forward. In a few cases, which at the time couldn't be identified until the procedure was started, the case would be much harder.

This is also why car repair shops have to really look at a car before giving a price.

That said, you are correct that for something specific we really need price transparency.
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Quote from Halfspin View Post :
1. I tried that route. "If I was paying cash how much?" still no number. I tried, "can you give me a ball park 100s or 1000s?" No answer.
Read "The Bitter Pill" in Newsweek.

2. Haha, I had mentioned my ailments to a Dr. friend of mine who said it was probably a good idea to get it check out and probably get some chest X-rays.
I've read the article, I agree that hospitals need more transparency on their charging. If you were talking with your pcp about this, they may not have been able to give you a quote if they don't do imaging in house.


2. It would be different if you went in and been examined and then asked your care provider if a chest xray would be beneficial. Calling in saying you thought you needed one may have made them nervous. Dr. Web Mds aren't great patients.
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#2 is so right on. As pointed out, it's already happening in a lot of states. One thing that no one is allowed to dare question right now are the high salaries of specialists and administrators at these (nonprofit) hospitals. That's a conversation that will start to take place in a couple of years especially as insurers are more regulated and govt becomes a bigger stakeholder.
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Quote from ZeeDuck View Post :
This is also why car repair shops have to really look at a car before giving a price.

yes, but most give free quotes and a warranty.

how many doctors do this?
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Quote from empiretc View Post :
yes, but most give free quotes and a warranty.

how many doctors do this?
Almost all doctors will give you a quote if you ask for it. I always ask for quotes if the procedure is non-emergency. One hospital would give a 10% discount on the quoted amount if you paid in full before the procedure.
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Quote from rhornback View Post :
Obamacare and the government's 'solutions' to medicine don't make any sense. They seek to increase revenue, decrease disbursements, but what about health care costs?
1) it allocates additional dollars to aggressively go after medicare fraud. http://www.healthcare.gov/news/fa...2012a.html

2) when more people are insured, more have access to PCPs which means use of lower cost healthcare instead of emergency rooms. And those debts are often uncollectable and result in higher prices for care for those who pay.

3) it funded pilot programs across the country to find ways to cut costs that, if the program is found to be successful, could be used as a model for the rest of the country. (This is what happened back in the day when we had a food shortage--it resulted in massive advancements in farming technology)

4) increases funding to implement electronic medical records. This will, once fully implemented across the country, will streamline payments/collections from insurance companies (which accounts for a significant amount of doctor expenses/overhead), reduce over billing, reduce duplicative testing, reduce medical errors, etc., etc.

Quote :
Obamacare seeks to expand the number of insured. But what effectively this means is people who are healthy (usually the young) subsidize the unhealthy and older people. How is this fair? If you are healthy, you pay more for the unhealthy? Young people, already overburdened by college debt and with limited job prospects are now going to get an additional 'tax' by requiring them to get health care? A tax which is not just on them but their employers. This tax decreases the likelihood that they will get a job.
That is the essential nature of insurance. Why is it fair that i have to pay premiums to my insurance company to pay for people who get in accidents?

Quote :
On the other hand, the government wants to decrease medicare disbursements. OK, but how do the hospitals and doctor offices function? I guess it is up to the doctor's to figure out how to cut their own costs.
In some respects, yes. Overhead for doctors' offices is regularly north of 50%!! That is nuts. The offices that implement EMR and find ways to reduce those costs will result in higher payments. Otherwise, large hospitals will start taking over (which is already the case) because they can be more efficient.

Quote :
1. Decrease the years of education to get a medical degree. As I have posted in the past, in other countries students go directly into medical school, they do not first get a bachelor degree.
That is nuts. There is a reason why our doctors are the best trained. And FWIW, residency programs that accept these newly "trained" students from other countries dind these kids are behind the curve.

Quote :
2. Allow for more routine medical checks to be done by nurse practitioners. Most medical care is routine and doesn't require a full fledged doctor. Routine care should be done by nurse practitioners with a single doctor at the medical center, or who can refer patients to doctors for more complicated medical issues.
Already happens. Physicians assistants are also used.

Quote :
3. Decrease medical liability. There needs to be a cap on medical liability. Yes I am sorry for those who have been injured, but regardless on whether we like it or not mistakes happen. A cap on medical judgments indexed to the consumer price index is needed to decrease the cost for the the doctor's and the hospitals liability insurance (which of course gets passed on to the patient).
Interesting. First you decrease their education. Then you have people be seen by someone other than the doctor and now they aren't responsible for mistakes.

Look, i'm all for getting rid of the "guarantied outcome" mentality. Mistakes happen. But we need to make sure hopitals innovate to make sure they reduce mistakes, errors, etc.

And this accounts for a VERY VERY VERY small portion of healthcare costs.
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#15
Quote from roughnready View Post :
#2 is so right on. As pointed out, it's already happening in a lot of states. One thing that no one is allowed to dare question right now are the high salaries of specialists and administrators at these (nonprofit) hospitals. That's a conversation that will start to take place in a couple of years especially as insurers are more regulated and govt becomes a bigger stakeholder.
11 states allow NPs to operate with no MD involvement, New Mexico has had it for 20 years. Any evidence that it has mitigated the cost of health care?
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