Government Health Proposals
Avrum Lapin
Re Public Option/ Insurance pools/Assigned Risk plans
My alternative would be to allow individuals or employers join the
largest pool of insured Americans - the people who work for the Federal
government. Federal employees have the choice of a number of plans each
with slightly different coverage, premiums, deductibles and copays.
After an open enrollment period of 6 months or so outsiders would have
to sign up within say 60 days of losing or quitting their existing
health insurance plans or pay a penalty. Premiums would be the
governments cost plus say a 2% (from COBRA) fee for admin costs.
(probably about $400/mo for the 60-65 crowd) Who would lose - insurance
agents who get commissions from selling health insurance.
OR
They could sign up with Medicare. Persons without a work history (e.g
elderly immigrants) can buy Medicare Part A (Hospitalization) for $460
/mo and can buy Part B (physicians and outpatient) for $96.40 (for the
lowest income tier). Since S96.40 only covers about 25% of Part B costs
a full share of cost would be overt $800/mo (pricey isn't it).
Assigned risk plans are fairly pricey - California's plan (MRMIP) has
monthly premiums of over $800/mo for a high deductible 70/30 PPO plan
for people aged 60-65
Re: Co-ordination of care etc
If co-ordination of care etc was that effective in reducing costs then
Kaiser (a non profit HMO) would have significantly lower premiums than
conventional HMOs or PPOs. Guess what - there isn't much difference.
Cost reduction
No one really knows how much care is "defensive" care against
malpractice lawsuits and how much is just racking up the meter. When I
had really good insurance from work I always wondered whether that
second doctor's visit to see if the meds worked wasn't just racking up
the meter. After my employer switched to an HMO I wondered if I was
missing something by not going back. I think we need some defined
"standard of care" and if the doctor thought that more care was needed
he would have to justify it.
When we reduce fees to the provider, the provider has to hustle more
patients through the office and we will get less face time with the
provider and more with physician's assistant. We will find "clerical
types" in white coats taking our blood pressure etc. Lower payments
far enough and we will have Russian style medicine
We need to think more about "end of life care". We might be better off
in a hospice with palliative care than undergoing another round of
complex surgery so that we can squeeze another couple of weeks of life
hooked up to machines. I hope that when my time comes to go into a
nursing home I have the strength to reach down and unplug the machines.
Other thoughts
How much of one's income should one have to pay for health insurance.
Should you be forced to give up cable TV or pricey cell phones?
Should you be able to buy a lower level of care with the understanding
that you are on your own and would be forced into MediAid if you can pay
Ron Peterson
> Assigned risk plans are fairly pricey - California's plan (MRMIP) has
> monthly premiums of over $800/mo for a high deductible 70/30 PPO plan
> for people aged 60-65
My sister, because of pre-existing conditions, pays $1200 per month
for her insurance.
> No one really knows how much care is "defensive" care against
> malpractice lawsuits and how much is just racking up the meter.
"Defensive" medicine is also good for the patient when it helps get an
accurate diagnosis.
Preventive medicine is what can reduce medical costs.
> �I hope that when my time comes to go into a
> nursing home I have the strength to �reach down and unplug the machines.
A broken leg may only require a few days in a nursing home.
> How much of one's income should one have to pay for health insurance.
The major medical part of health insurance is where the problems lie.
The government needs to deliver enough care to keep people working or
at least out of nursing homes.
> Should you be able to buy a lower level of care with the understanding
> that you are on your own and would be forced into MediAid if you can pay
The problem with high deductible insurance is that the insurance
company doesn't bargain lower fees from the doctors and hospitals.
--
Ron
Bill
> Federal employees have the choice of a number of plans each
> with slightly different coverage, premiums, deductibles and copays.
Which highlights another problem with the current system. Unless you
are an attorney with a lot of healthcare knowledge and time to invest
reading the policy it is very difficult to compare policies and know
exactly what you are getting.
One of the best things I discovered about Medicare when I reached 65 is
that there are a reasonable number of medigap plans (12 I think) whose
benefits are precisely defined by Medicare. So if you decide that plan
F is right for you you can then compare the cost of plan F among
various vendors and know with absolute certainty that you will get
exactly the same coverage no matter which vendor you pick. That forces
the insurers to forcus on being the low cost provider instead of trying
to make money by limiting claims. Anything that forces the focus to
cost control is a good thing.
--
.Bill.
Bill Woessner
> The problem with high deductible insurance is that the insurance
> company doesn't bargain lower fees from the doctors and hospitals.
Not true of my high-deductible health plan (from Great West, recently
acquired by Cigna). I pay the insurance company's negotiated rate.
AND I pay it with pre-tax dollars, which is a pretty significant
savings.
--Bill
Avrum Lapin
wrote:
Medicare funds no charge counsellors (the SHIP program) who will help
you compare your options in dealing with the costs that Medicare does
not cover. The major difference between Medigap policies are those
which use age related premiums and those which use county based
premiums.
Wallace
"Bill Woessner" <woes...@gmail.com> wrote in message
news:dfeb149c-e393-4086...@12g2000pri.googlegroups.com...
I concur with Bill.
Bill
> "Defensive" medicine is also good for the patient when it helps get an
> accurate diagnosis.
That is not what is generally understood as "defensive" medicine.
Defensive medicine is diagnostic testing which has no medical benefit
and whose sole purpose is to provide documentation for defense of a
malpractice suit.
--
.Bill.
Bill
> Not true of my high-deductible health plan (from Great West, recently
> acquired by Cigna). I pay the insurance company's negotiated rate.
> AND I pay it with pre-tax dollars, which is a pretty significant
> savings.
Exactly. Even if you get a policy with a deductible that is so high
that it does not qualify for the tax benefit you are still way ahead
because you will pay the contract rate for services even though you are
paying 100% of the bill and the insurer is paying nothing.
--
.Bill.
BreadW...@fractious.net
> On Nov 10, 6:57�pm, Avrum Lapin <avrum...@verizon.net> wrote:
>
> > Assigned risk plans are fairly pricey - California's plan (MRMIP) has
> > monthly premiums of over $800/mo for a high deductible 70/30 PPO plan
> > for people aged 60-65
>
> My sister, because of pre-existing conditions, pays $1200 per month
> for her insurance.
Depends very much on the state. In states with variations on
community rating, the most expensive folks to insure get rates
that are limited by law -- typically to something like 200% of
the rates they charge the youngest and healthiest folks.
Naturally, that means that in those states, the youngest and
healthiest pay much higher rates than in states without
community rating (and leads to higher rates of uninsured
healthy young people).
In a few states, community rating is imposed on small group
plans (ie. small employers). In even fewer, community rating
is imposed on individual plans as well.
The variation in cost if you are an individual pricing a plan
in a non community rating state against a plan in a state which
has it is quite instructive. In my own family's case, our rate
in a community rating state was approx 2x the cost for a
similar plan in a non-community rating state.
> The problem with high deductible insurance is that the insurance
> company doesn't bargain lower fees from the doctors and hospitals.
They do. Someone with a typical HSA high-deductible plan
gets the same negotiated "network" rates as folks in the
traditional plans -- and typically very much cheaper than
the standard billed rates that providers attempt to charge
the uninsured.
The whole business needs vastly more pricing transparency.
Having one's health insurance paid for by one's employer,
thus hiding the cost of the insurance itself, and then
having the bills paid directly by the insurance company
to the providers without the patient ever seeing the actual
costs is an obvious recipe for inflation. Folks will always
use more of something that doesn't seem to have any price.
HSAs and high-deductible plans may not be perfect, but they
are a vastly better approach to this lack of transparency
than the alternatives currently in place.
(Then there's the whole issue of getting employers out of
the loop entirely - it would be hard to contemplate a worse
plan than having one's employers provide this stuff. And
the current bill that the House passed actually makes the
employer entanglement *worse* rather than better.)
--
Plain Bread alone for e-mail, thanks. The rest gets trashed.
Are you posting responses that are easy for others to follow?
http://www.greenend.org.uk/rjk/2000/06/14/quoting
Will Trice
> Preventive medicine is what can reduce medical costs.
You would think, but apparently not. I was listening to an interview
with a former U.S. Surgeon General (didn't catch which one) on NPR. He
made the point that preventive medicine reduces medical costs for an
individual but in most cases not for society. As an example, the total
cost of screening most or all women periodically for breast cancer via
mammograms is much higher than the cost would have been to treat those
women who's cancer went undetected until a late stage since relatively
few women end up with breast cancer.
His point was that the benefit of most preventive medicine is better
outcomes, like catching breast cancer early, not saving money.
-Will
will dot trice at comcast dot net
Ron Peterson
http://www.acpm.org/breast.htm recommends screening for breast
cancer.
To only look at mortality in determining cost effectiveness is short
sighted. Breast cancers that are caught early involve less trauma to
the patient and shorter recovery with less physical therapy. Better
outcomes save money.
--
Ron
Bill
> Better
> outcomes save money.
Even if better outcomes do not save money better outcomes are a
legitimate goal in itself. What should the goal be?
1) Provide the lowest cost care possible.
2) Provede the best outcomes possible with the resources that we decide
to devote to healthcare?
--
.Bill.
Will Trice
> To only look at mortality in determining cost effectiveness is short
> sighted. Breast cancers that are caught early involve less trauma to
> the patient and shorter recovery with less physical therapy. Better
> outcomes save money.
I disagree; with the notable exception of most vaccination programs,
better outcomes are more cost effective, but they do not save money.
That is to say, money for preventive medicine is money well spent, e.g.
breast cancer screening, but in most cases the cost over all patients
(including those who will never get cancer) is typically higher than the
total of treatments. An individual might save money, but not the
healthcare system itself.
Ron Peterson
Government goals should be to
a) keep people able to work as long as possible
b) keep people out of assisted living or nursing homes as long as
possible
--
Ron
Bill
> Government goals should be to
> a) keep people able to work as long as possible
> b) keep people out of assisted living or nursing homes as long as
> possible
Also, there have been many persuasive studies espousing the theory that
seeking better outcomes, as you propose, although they may not be the
lowest cost to the healthcare system are the lowest cost to the economy
as a whole.
--
.Bill.
dapperdobbs
The early part of this discussion had to do with insurance plans. With
home insurance, one insures against a 1 in 1,000 event. With medicine,
it seems insurance is supposed to translate into getting virtually
unlimited service for a fraction of the cost - and more than 1 in
1,000 people grow old and die. Insurance adapted to a "privitized
socialism" and services declined, contracts became complicated, and
the front desk got surprised and called people who actually paid,
"self-insured." (I'm waiting for the check-out chick to say, "Oh ...
you're self-grocered?") Now the issue is whether or not to make it
100% enforced socialization.
One's life, health, and manner of death are one's own responsibility.
Would you want it some other way?
Elle
> Ron Peterson wrote:
> > Preventive medicine is what can reduce medical costs.
snip stuff for brevity, especially stuff on breast cancer prevention
Breast cancer screening has become highly controversial, because too
often it yields a wrong diagnosis, and so in fact is not screening at
all, leading to unnecessary invasive procedures. I think one has to
remember that some doctors profit from the equipment and clinics
involved in mammograms. From my reading, it is overprescribed (in
particular, among younger women), and the overprescription does not
change outcomes.
Safeway chair and CEO Steve Burd has been experimenting with health
care reform within Safeway, in particular giving Safeway employees
incentive to practice preventive medicine. According to him, the
dollars Safeway loses to providing incentive are more than made up by
the dollars Safeway saves in health costs.
>From an interview with Burd, per http://online.wsj.com /article/
SB124536722522229323.html:
---
The second part of Safeway's plan was an embrace of the obvious:
Healthy people cost less. Mr. Burd notes that 75% of health-care costs
are the result of four conditions cardiovascular disease, cancer,
diabetes and obesity. The majority of these are preventable. "Obesity
in this country went from 18% to 40% in 20 years -- this is not
genetics, this is behavior," he explains. He says that an obese
employee can require 10 times the number of doctor visits in a year
than someone of healthy weight.
The result was Safeway's "Healthy Measures" program, which is
voluntary. Employees are tested for smoking, weight, blood pressure
and cholesterol. Every area they "pass" results in a reduction in
their premium, of as much as $1,560 for a family, a year. Those who
fail but prove progress can get refunds. Safeway complements this with
an intense culture of health: weight-loss tips, fitness competitions
and smoking cessation programs.
Critics of price incentives argue that they pressure consumers to
forego necessary care. Mr. Burd counters that Healthy Measures and the
company's free preventive care -- designed to catch problems before
they become expensive -- have in fact resulted in a healthier work
force. Safeway's smoking and obesity rates are roughly 70% the
national average. The program has even been cautiously greeted by
Safeway's union leaders, who understand that soaring health costs are
eating into union wages.
---
Elle
> You would think, but apparently not. �I was listening to an interview
snip for brevity
> His point was that the benefit of most preventive medicine is better
> outcomes, like catching breast cancer early, not saving money.
This is not the point I took from reading at
http://www.npr.org/templates/story/story.php?storyId=120183531&ft=1&f=1057
. Here is the quotation that seems to sum things up, by former
assistant surgeon general Douglas Kamerow:
"Preventive services are worth it if they improve health at a
relatively low cost. The way we control health care spending is by
moving our money from expensive low-value services - both treatment
and prevention - to more cost-effective, but not cost-saving, high-
value interventions. That means fewer expensive drugs that extend life
a week or a month. More proven early interventions that can extend
life for years or decades.
Yes, prevention does not save money, but effective preventive care,
like effective treatments is a crucial part of a reformed health care
system."
ISTM Kamerow is stating the obvious: Do not waste money on
preventative care not shown to be preventative.
BreadW...@fractious.net
> The early part of this discussion had to do with insurance plans. With
> home insurance, one insures against a 1 in 1,000 event. With medicine,
> it seems insurance is supposed to translate into getting virtually
> unlimited service for a fraction of the cost
One of the minor annoyances I find in much of the discussion
about healthcare is the fact that, as you are indicating here,
what folks talk about is health care -- but they keep using
the words "health insurance". Our system has some aspects of
insurance, still -- in that if you have one of those 1 in 1000
events, the amount that you have to pay out of pocket is
generally capped. But it's also, as you are saying, become a
system of prepaid medical care wherein folks have prepaid (or,
more commonly, their employers have prepaid) for a bunch of
basic medical care at a prenegotiated discount. And since
the end user never actually sees many of the bills or costs
(and worse, there's often no marginal cost for services at
all), nobody should be surprised at an overuse and cost
spiral.
In a more traditional approach, insurance is purchased to
protect against unlikely events which, if they do happen,
would cause major problems. (Well, permanent life insurance
is the traditional exception, inasmuch as everyone dies, but
even that is really built out of a pair of things, one more
of a savings and the other the actual insurance part).
The push for HSAs with HDHPs is something of a return to the
traditional role for insurance, and studies have shown that
they do lower folks spending as they make them much more
conscious of the costs.
In the larger societal sense, there's a place for some sort
of backstop on folks catastrophic costs. Just like we have
bankruptcy protections because at some point, there's just
no geting out from some situations, similarly, at some point,
it's just not realistic to expect folks to be able to pay
for catastrophic care out of pocket. Whether that backstop
is fully private or provided by the government (and paid for
via broad taxes, hopefully, rather than by forcing employers
to foot the bill), that backstop needs to be there. Nobody
should be bankrupted due to medical costs -- if they are,
there is really no large societal savings, since they then
become dependent on the rest of us anyway (and they fall
into the welfare and medicaid system).
> One's life, health, and manner of death are one's own responsibility.
> Would you want it some other way?
Sure. But we've already made a commitment that at some
point, when folks are in catastrophic circumstances, we
are going to take care of them. We don't want folks dying
in the streets, or even living on them or starving. The
trick is to make sure that they bear the burden and take
responsibility as much as possible, but not more than
possible.
Not that the House bill really addresses this distinction
all that much as far as I can tell. And not only doesn't
it do anything about the entanglement of employers and
employment, but actually makes that problem (and it is a
huge part of the problem here) worse.
Will Trice
>> His point was that the benefit of most preventive medicine is better
>> outcomes, like catching breast cancer early, not saving money.
>
> This is not the point I took from reading at
> http://www.npr.org/templates/story/story.php?storyId=120183531&ft=1&f=1057
> . Here is the quotation that seems to sum things up, by former
> assistant surgeon general Douglas Kamerow:
> ISTM Kamerow is stating the obvious: Do not waste money on
> preventative care not shown to be preventative.
>
And, as I stated, that most preventative medicine does not save money,
"Here's the dirty little secret: most prevention doesn't save money any
more than treatment saves money." (from your link).
Thanks for posting the link - Kamerow that was the dude's name!
--
Bill Woessner
> The whole business needs vastly more pricing transparency.
> Having one's health insurance paid for by one's employer,
> thus hiding the cost of the insurance itself, and then
> having the bills paid directly by the insurance company
> to the providers without the patient ever seeing the actual
> costs is an obvious recipe for inflation.
Amen to that. And I think the tax code adds yet another layer of
opacity. Or, at the very least, it makes it hard to perform an apples-
to-apples comparison. Suppose you get your health insurance through
your employer and you think you're paying too much for it. There are
two major obstacles to shopping around for health insurance.
First and foremost, there's the employer contribution. If you opt out
of your employer's health insurance, your employer isn't likely to
just fork over their contribution. My employer adopted a "cash-in-
lieu" plan this year. If I opt out of their insurance plan, they'll
pay me $100 per month. That's about 1/5 of what they actually pay for
my insurance.
The other obstacle is the tax code. Any money you and your employer
put toward your employer-provided health insurance is pre-tax. If you
opt out of your employer's insurance and (somehow) receive that money
in your paycheck, you'll pay taxes on it. Assuming you're in the 25%
federal bracket, below the Social Security wage base, and 5.75% state
income tax, you'll lose 25% + 5.75% + 15.3% = 46.05% of that money.
You can deduct your premiums from your federal and state taxes, but
only if you itemize and only the amount that exceeds 7.5% of your
AGI. Not exactly a level playing field.
--Bill
Bill Woessner
> Breast cancer screening has become highly controversial, because too
> often it yields a wrong diagnosis, and so in fact is not screening at
> all, leading to unnecessary invasive procedures.
Just to follow up on Elle's post... I'm sure most of MIFP crowd has
already seen this. But just in case.
http://www.cnn.com/2009/HEALTH/11/16/mammography.recommendation.changes/index.html
--Bill
Bill Woessner
> The early part of this discussion had to do with insurance plans. With
> home insurance, one insures against a 1 in 1,000 event. With medicine,
> it seems insurance is supposed to translate into getting virtually
> unlimited service for a fraction of the cost - and more than 1 in
> 1,000 people grow old and die.
I strongly agree with this sentiment. Health "insurance" has morphed
in to something more closely resembling health maintenance. A good
example of this is preventative medicine. We've heard all about how
health care reform should force insurers to pay for preventative
medicine. There's just one problem with that. You cannot insure
against the cost of preventative medicine. It's a known cost. It's
unnecessarily expensive to have health insurance cover preventative
medicine. It's much more efficient to pay providers, directly.
It's fair to talk about subsidizing preventative medicine for the
poor. That's a different, albeit related topic. But "insuring"
preventative medicine is just plain silly. The only possible win is
for the insurer (in the case you don't actually obtain the
preventative medicine).
--Bill