Paying for Health Care

I have found a lot of confused thinking on the right lately regarding how to pay for health care. The left is hopeless but items like this, complaining about the FDA taking Avastin off label for stage four breast cancer don’t get to the heart of the matter. What is the right process to figure out whether you’re going to undergo a medical treatment?

Even if you are independently wealthy and have no insurance to complicate things you would not limit your consideration of treatment to just the medical discussion with your doctor. Your financial team would come into play as questions of bankruptcy, how much this is going to impact your estate, etc. are going to affect your decision. And in that discussion, if your sole heir starts getting creepy and talking down all the expensive treatments, you have a problem.

Putting insurance into the equation doesn’t change the conversation. It just adds a large cast of characters to the discussion and some extra money that you don’t control. The possibility of somebody going creepy and acting in their own best interests but not yours is still there. In fact, the more distant the 3rd parties, the more likely it’s going to happen. Add in the government and the chance explodes.

The FDA and Medicare are acting like the creepy heir on the make and there are a lot of people who sense it without being able to articulate it. Nobody can *prove* anything, but the vibe is not good.

4 thoughts on “Paying for Health Care”

  1. Cost has been the driver since 1978 when PSRO came to the table. That is supposed to mean “Professional Standards Review Organization.” We were told it was about quality but all the directives and the studies we were instructed to run had cost as the basic criterion. Eventually, the intrusion became more onerous and I decided to join the enemy to find out how it worked. I spent years on the Board of CMRI, the California Medical Review Inc. A few of us who really took care of patients got on the board and we felt we made some difference.

    Eventually, I concluded that cost is almost the only measurable data point except death and the others are all parameters for cost. When I retired due to a back injury, I went to Dartmouth for a year to try to learn how to measure things other than cost as a criterion for quality. It is possible and I returned to California in 1995 planning to start a new career in measuring quality. For a while, I got referrals from Dartmouth which were usually insurance companies. I explained the methodology and the medical director would tell me that he would speak to his board and get back to me.

    They never got back to me and I concluded that they all feared good quality would be more costly. That is actually not true in most instances. The problem is that no one in the insurance or payer business understands that there are parameters other than cost which can help you direct your incentives. Preventive medicine, which is constantly being pushed by people who know nothing about it, does not save cost except in the area of public health. The DDT ban is an example of how politics affects these areas and makes any real analysis useless.

    We will never get a handle on cost until we allow the option of a cash system for routine care and insurance for catastrophic events. That is what we had in the 1950s when cost was not an issue. New technology made the equations more complicated and led us into the mess we see now. Still, most of that technology matures and there should be something like Moore’s law in medicine. Avastin is very expensive becaue the production is costly. As more indications appear, production will increase and the price will come down. Maybe, in the meantime, people should buy a policy that includes catastrophic drug cost. I’m sure such a policy would be available once the market allowed such things.

  2. We will never get a handle on cost until we allow the option of a cash system for routine care and insurance for catastrophic events. That is what we had in the 1950s when cost was not an issue.

    I am in complete agreement with the conclusion, but I remember things differently. What we had, and this may be what you meant by cash system, was the customer (patient) obliged to pay for all care with reimbursement to the patient from the insurance company after the fact for any covered costs.

    The veracity of the quoted statement can be demonstrated by a current example, cosmetic surgery, about which I hear few price complaints, which is generally not covered by insurance yet has practices that can afford extensive advertising on print, radio, TV and billboards in my podunk market (about MSA 100).

    The source of the problem is not the PSRO, in my opinion, but the pact the AMA made with the Devil in 1965 when Medicare was approved. As I recall there was real discussion of the AMA members refusing to accept payment from the government because it interfered with the Doctor-Patient relationship. How right they were. But the doctors ultimately caved for the almighty $ and political pressure and they too have suffered for it. That was when the government and insurance companies gained control. After that, PSRO and its progeny were inevitable.

    But there has also been a change in doctors, perhaps also a result of the deal with the Devil. (And not just doctors. All the professions, the ministry, law, accountancy, teaching, you name it have abandoned even the appearance of the high ethical standards that existed in the ’50’s and before. The only possible exception I can think of is engineering, and that’s probably because people frequently die, clearly unnecessarily, when engineers make mistakes.) It is said that 2/3rds of what is spent on health care is spent in the last two years of one’s life. Having watched my father, father-in-law, and mother-in-law die over the last 10 years I can believe it.

    I also saw no Dr. Kildares in my parents’ treatment. And the nurses were so overworked they hadn’t time to provide solace. All the dozens of doctors ordered the necessary tests as prescribed to cover their butts without regard for their impact on the suffering patient, often over patient objections, and without consideration for the fact that the tests would have no impact on the treatment of the patient or the course of the disease. The only time I saw a medical professional provide a dying human being the dignity they deserve was when we finally got to the hospice. The treatment of patients in the practice of the art of medicine has been utterly supplanted by the application of scientific and financial principles to treat subjects in the well defined, bureaucratically prescribed fashion handed down from on high. And the patient suffers for it.

    I look forward to seeing the entire rotten edifice crash in on itself and a return to fee for service and the practice of the art of medicine, not the application of science to subjects. But I haven’t long to live and my eyesight isn’t what it once was. Perhaps I should call my opthamologist tomorrow.

  3. The only possible exception I can think of is engineering, and that’s probably because people frequently die, clearly unnecessarily, when engineers make mistakes.

    I am so glad I decided to become an engineer. #3 son and #1 daughter are also studying engineering. Warms me heart.

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