I'm going to get flamed for my opinion on Healthcare but here it goes

[AllentownJake]

Real quickly my background, I'm an accountant, well actually an auditor who spent a year auditing hospitals and the past 2 years auditing a medicaid HMO. I'm by no means an expert on the system but here is what I know


1) Claims are good. Claims capture data on cost and allow you to track cost of a person recieving healthcare and look for opportunities to treat the person in a more efficient manner. If the person is constantly going to the emergency room for treatment than it makes sense for a utilization management nurse to talk to that person about going to a Primary Care Physician once a year for a check-up and for their sore throat before it becomes something worse. If we managed utilization managment better the emergency room can go back to what it is meant to be a triage center and not a free health clinic. Utilization management is also good for drug treatment and serious illness treatment. You want the best care possible and you want it in the most efficient way possible.

2) You have to have a way to control cost. I believe Healthcare is a right but trust me you have to set up a system of checks and balances. I believe a system where the government takes on risk, outsources administration to a third private party licensed and audited by the state on an annual basis, and the third party pays the hospitals. The third party recieves credit for managing costs and utilization management. You set up 3 parties that can lobby and control each other and you create a system that is less prone to playing with the politians because you now have a business interest that has a reason to try to keep the republicans out of messing with their system.

Now flame away.

[L0oniX]

1. ...

[DireStrike]

2. Seems to me like the third party is meaningless

The government is already taking on all the risk. Auditing decisions that have already been made is not exactly control.

And what would be the form of this third party organization? It better not be anything looking to make a profit. The only costs in the system should be administration. Those costs should go to the workers who manage, and should be reasonable - none of the sky-high salaries that private sector executives get because they all know each other, practically in the biblical sense. Are you sure some third party entity can manage that? Why should we give another party negotiating power? "You hired us because we know what we're doing, so back off!"

[AllentownJake]

7. Medicaid HMOs

Look into them.

[supernova]

11. HMOs, no thanks

I'm all for everyone having a family GP for general purposes, but HMOs do too much gatekeeping at the expense of the patient.

I'm one of the ones who legitimately needs a specialist. I am very well educated about my condition, to the point I can out talk and out think MDs outside my dicsipline. I would have no patience AT ALL for having to say requalify to see my specialist every time I need an appt.

[AllentownJake]

14. If you need a specialist

You get a specialist...the medicaid HMOs are alot different. Just because it says HMO doesn't mean its the same as you are thinking.

[geckosfeet]

3. How is this system much different from what we have today? And how does it

ensure that everyone is covered?

By implication this system (a for profit system) ensures that there will always be a large and growing segment of the population (read poor and unemployed people) that will be unable to afford health care.

[AllentownJake]

5. Government covers risk

people have choice over which administrator they choose. Companies are paid by member.

[geckosfeet]

Ahhh. An institutionalized bailout program. Eliminate the profit motive

and make the primary mission providing health care to everyone.

[AllentownJake]

17. We live in a capitalistic society

this keeps profits low and gives government the ability to control costs. At the end of the day we'll be paying for it and I want an efficient system that produces resutls.

[geckosfeet]

97. We have seen how the profit motive works. Why do people still cling to it?

[OregonBlue]

4. Medicare admin costs are 3%. Private company costs are much, much higher. Why do you assume that a

private company could do a better job? I worked for a large HMO for many years. There is a great deal of waste in the administration with private healthcare companies. Perhaps private companies could do audits and best practice analysis but that's about all they should be allowed to do.

[AllentownJake]

6. Because they actually do a better job for Medicaid

which is where I work. people have a choice in plan administrators which takes away the choice argument from the rethugs.

Medicaid provides more managed care services and utilization management than medicare.

[supernova]

10. And they are chronically underpaying docs

to the point that they are unwilling to take medicaid patients or at least no new ones.

what do you propose to do about that?

[AllentownJake]

15. Tell the state to stop cutting the MA fee schedule

We don't decide what we pay Drs. the State does.

[supernova]

22. I understand that

And it comes from the Republican notion of starving gov't programs in order to INSURE they don't work. This, along with the private profit motive must be eliminated entirely over the coming generations.

Get it?

[AllentownJake]

27. Actually Ed Rendell starves us

everytime he has a budget problem.

Last time I checked...he has a HUGE D behind his name.

[knixphan]

74. zactly.

[AllentownJake]

77. Why does my Democratic govenor do it than?

[supernova]

82. Because he has bought into that same thinking from the GOP

Is Rendell DLC or DLC friendly?

Too many moderate and "conservative" Dems in office have co-opted some Repub/conservative ideals. They think that's how they have to get elected and stay in power. The idea that Gov't "costs too much and private cos can do better" is chief among them.

[supernova]

8. No Private Businesses; No Profit!

Profit is the deathknell of good healthcare.

"Controlling cost" is the accountant's way of saying "I think people use healthcare too much that they don't deserve."

I do however, agree with you about ERs and managing chronic illness.

[Statistical]

12. A public only healthcare won't have control costs is also false

Saying controlling costs = bad is a straw man.

Any public healthcare system in the world uses measure to control costs.

If they didn't quickly healthcare costs due to fraud, waste, and abuse along with the "I want the best of everything at all times. Run every single possible test" scenario would bankrupt any govt.

There will be cost controls in a public only healthcare system
There ALREADY are cost controls in Medicaire/Medicaid.

The OP belief is that we can have a public-private partnership.

Public funds. Universal access. Universal choice of plans. Plans run by private companies.

Honestly I think this is the only route that will happen. The healtcare lobby is very powerful. Many states have large number of jobs based on healthcare management & insurance. The idea that those Reps & Senators will suddenly "see the light" and allow the interest of their states to be hurt for the "common good" is a fantasy.

We will only get support for universal healtcare if it has a private angle.

[supernova]

20. No private plans

I didn't say controlling costs is a bad thing.

I say controlling costs so private firms can turn a profit is a very bad thing when it comes to healthcare.

You control costs by looking at,

1) as you say, making sure chronically ill folks stick to their routines including meds and doc visits, and any lifestyle changes that might be required.

2) Getting rid of the profit motive. And before you scream about this, does the military, which eats up more than any of the other activites combined every year, turn a profit for the gov't? No, it turns a profit for the Beltway Bandits who get fat Dod contracts.

We can get support for public healthcare, just like Soc Security.

[joeunderdog]

79. cost control = preventative approach to health problems

you can't wait til the horse is out of the barn.

[AllentownJake]

18. That's my concern

and as an accountant I want my government to be efficient whether it is the military, healthcare, or building roads.

[shraby]

9. Wasn't trying to keep the government out

of messing with a system is why the stock market/housing market/corporate market what caused the whole system to collapse? Why then would this same type of system work for health care?

[supernova]

13. Yes, exactly

"Just leave it to us, we got it all covered. No need to bother us or waste your time."

:sarcasm:

[AllentownJake]

19. Fix your sarcasm

Regulation is part of the system...I see more regulators a year than I care to say. If my company steps out of line we lose our license or get heavily fined. Since there is more than one company doing what we do our members would be just moved to another company and wouldn't suffer too much from the transition.

[supernova]

21. I did and you are not understanding me at all

Any changes we make to institute public healthcare should always put the patient first. Period. And that's what I will always fight for.

You are saying let's put money first. FAIL.

[gravity]

23. Money will be an issue in a public funded health care

There isn't a unlimited amount of money for health care, and the state will have to make decisions on which treatments are most cost effective.

[AllentownJake]

26. DING DING DING

Yep if you have a 2% chance of survival you end up paying for the treatment yourself. Some people don't understand that is going to be something that will happen.

[AllentownJake]

24. I never said that

I want a system that is both efficient and one that takes care of the patient. I want my cake and my pie.

I'm sure there are smarter more experienced people than me writing this policy. Barack has my opinion in change.gov

FAIL right back at you

[AllentownJake]

16. Regulation is part of the system

If you want a system where in 8 years a GOP President can shut down the hospitals with the stroke of a budget cut...go for it.

[Donnachaidh]

29. no -- we want the for profit hospitals lobbying to put the non-profits out of business

Which is what they are DOING *NOW*.

Then we can have the poor and un-insured dying on the streets. Everyone else can sign over their homes, savings and first-borns to receive *care* at the for-profits. Of course, the for-profits push the MOST expensive drugs, push testing that may or may not be needed - all to pad the bills and sink the patients deeper into debt.

So the for-profits can build NEW wings on their hospitals, or more parking garages for the doctors.

Yeah -- the last defense of an argument going down in flames is the FEAR factor. Boogie, boogie, BOO. :sarcasm:

[AllentownJake]

30. You can speak talking points all you want

Try actually thinking about what someone is saying in a thread.

I love Michael Moore and enjoyed Sicko and agreed with him on many things but reform isn't as simple as you think.

There are smarter people working on this system than you and I and for that I'm grateful.

[Donnachaidh]

38. ahh, the shrill *talking points* argument

Coming from someone who BENEFITS from the free-market RAPE of the weakest individuals in our society -- the unfortunate SICK people.

I watched SICKO too. I also see the REALITY of so many people losing their livelihoods, their savings, their HOMES, their retirement funds -- because they got SICK.

I watch as the bean counters who PROFIT off the weakest of our society. YOU have a salary, YOU have medical benefits, YOU have a retirement income -- and all of it is coming from the the draconian insurance/HMO corporations that look at people as profits and losses.

Take some advice -- got get that other job. Do it while you CAN.

[AllentownJake]

40. I work for medicaid

I work for it because I actually give a shit if people in the poorer communities get good healthcare. I make things more efficient so there is more money to give back to those communities.

Now you can apologize now or later.

[Donnachaidh]

43. see #42.

as to the apology, hold your breath.

[AllentownJake]

45. Yes because I'm sure you work for a company

that provides lolipops to the homeless.

:rofl:

[Donnachaidh]

55. no dear.

I'm disabled.

I have to deal with schmucks like YOU in order to get minimal healthcare. Like I've said, your argument is based NOT on concern for the patient - it's concerned for your economic future.

[AllentownJake]

57. I'm sorry you are diabled

and I'm so sorry you are angry.

However, I am not your enemy.

[Donnachaidh]

62. there's that professional condescension again

I'll bet your especially smarmy when patients have to talk to you.

And guess what -- it's not anger I feel. Try looking up *cognitive dissonance*. I don't consider you an enemy. I consider you and the system you work for as dinosaurs that need to be put down.

[AllentownJake]

64. Fine

I don't work with patients. I work in the back office doing all I can to ensure people can get good care.

Have a nice day.

[Donnachaidh]

66. Uh huh.

Keep telling yourself that. But if YOU faced reality, and really looked at the people who DIDN'T get care because you *crunched numbers* and turned them down due to cost -- you'd find out differently.

YOU are part of the PROBLEM.

[AllentownJake]

68. You are on ignore

I hope you get the care you deserve and you can calm down on your anger.

[Donnachaidh]

71. again. the last resort of the desperate.

I certainly hope YOU don't lose that fine health insurance you bragged about in another post. You might have to deal with the reality of the health insurance nightmare.

THAT would be a hoot and a half, huh? :sarcasm:

[AllentownJake]

73. Did Ignored Say something?

[Donnachaidh]

76. ....

:rofl: :rofl: :rofl:

[moc]

59. Equating "working for medicaid" with giving "a shit if people in the poorer communities get good

healthcare" is a crock, sorry to say. At least it is here in Texas. I say that as the wife of a behavioral health care provider who sees almost 100% medicaid patients. You're not a provider, you're an auditor. The auditors here in Texas don't give a shit about providing care; they're all about controlling costs. I could tell you story after story after story about how my husband has been screwed by the Texas Medicaid program out of being paid for legitimately delivered mental health services to some of the neediest children and adolescents here in North Texas. I can't tell you how many times my husband has continued to provide care he knew he would never be paid for because the kid he was seeing needed it and had nowhere else to go. It's because *he* cares about serving these kids. Medicaid couldn't give a shit. It's no wonder there are no Medicaid providers around. Medicaid sucks.

[AllentownJake]

65. As a consumer of Behavioral Health

The entire system is fucked and I have better insurance than most it isn't getting better to non-behavior health care gets fixxed.

I'm working in the system we got and doing the best I can do in it. I guess it would have been better if I stayed in Financial Services....those guys aren't getting yelled at right now either.

[Donnachaidh]

25. as your income is derived from this greedy DEATHcare system

Of COURSE you are going to *fine point* everything. Of COURSE the system is GOOD.

Typical American response -- "Fuck the rest, I've got MY paycheck".

:eyes:

[AllentownJake]

28. I work for less than I could make somewhere else

because I work for one of the good guys in the current system. My company gives more money to the community and is more involved than any I have ever worked for.

I'm an auditor with lots experience in Sarbanes Oxely who is working in a non-Sarbanes company because I like helping them to be more efficient.

Even in this shitty economy I can get a new job tommorow.

Oh yeah and I spent 8 months volunteering for Barack because I thought it was the right thing to do when in reality neither guy would really effect me that much personally too old for the draft in a field that is always in need. I'm kind of :silly: like that.

[Donnachaidh]

31. that was YOUR choice -- you STILL contribute to the problem.

So even in this *shitty economy* you could get a new job? BULLY for you. Do you think you might be in a small way part of the reason why THOUSANDS of people are out of work now?

Do you even think you might in a small way be responsible for people losing their HOMES because they had the terrible misfortune of becoming ILL?

Whoopie! You got politically involved! And of course this makes working for a company that helps destroy the economy OKAY, right?

A field that is always in need? REALLY? Seems to me that perhaps your field may NOT be so *in need* if the government goes to single payer healthcare. I'll bet the government has a whole army of auditors already on the payroll to step in and take YOUR place, at a cost far less than what your company bills now.

tick, tick, tick goes the countdown.

[AllentownJake]

33. I WORK FOR A FUCKING MEDICAID COMPANY

Jesus Christ...if you want to get rid of Medicaid let me know.

[Donnachaidh]

42. if getting universal healthcare for everyone in this country means getting rid of Medicaid

Oh you betcha!

[AllentownJake]

44. Fine by me

but right now I'm doing the little I can for the people who are at the bottom end of the ladder.

Maybe you should talk to people instead of instantly reacting with words like rape and such.

[Donnachaidh]

51. truth hurts, doesn't it?

RAPE is THE appropriate word for it.

When I see seniors struggle to get prescription coverage, but are given not only a ration of shit because they were unfortunate enough to be diabetic - but they also have to pay astounding high premiums because some bean counter in an office somewhere decided the extraneous costs like syringes or tubing is something they wouldn't cover? After all diabetics really don't NEED syringes, now do they?

Or the elder who needs oxygen, but has to pay out of pocket for the TUBING to use that oxygen -- this of course, after paying for BOTH his medicare part A and B, which is usually 10% or MORE of a VERY limited income in the first place?

You DARE to get *offended* by the use of a WORD?

Okay -- How about this? How MANY seniors, how many disabled people are MURDERED every year by insurances and agencies that drag their feet, diddling over terminology, diddling over how *much* of a service they will provide, or how much of a drug they will provide?

Got any STATS on THAT?

How many people DIED in emergency rooms while hospital office workers ran around trying to figure out which form to send, who had jurisdiction over the poor elderly sod who was brought in by ambulance?

Got any STATS on THAT?

[AllentownJake]

53. RAPE is the appropriate word for RAPE

I don't trivialize that word by using it in arguments.

[AllentownJake]

56. BTW

If you actually articulated your arguments without going on the attack right away with someone you'd like to change their mind...well

you might not be discounted as a nutcase right away by the other person.

[Donnachaidh]

60. namecalling is the last point made by the desperate.

And I'll bet you use your condescension all the time in your line of work.

Must be frightening thinking that the patients are now speaking up, and they aren't being nice when discussing the abuse they've been dealt for decades.

[AllentownJake]

67. Your such a sad person

(EOM)

Stop projecting your feelings on the entire system on me.

[Donnachaidh]

69. there's that cognitive dissonance again n/t

[Two Americas]

102. if you are one of the good guys...

..why don't you talk like one?

Why should any of us care about propping up your self image as one of the good guys, and why is that so important to you?

I would say that your self-awarded credentials as a good guy is being used by you to give yourself license to speak and think and act as a bad guy.

[ProfessorGAC]

58. But, The OP Doesn't Say That

Like many folks, the OP suggests that there are good elements to what we have, but if there's a better way, then they're ok with it.

The OP doesn't say "as long as i get my paycheck. . ." It's not even close to that.

I think you're misdirecting your anger at someone who doesn't have any control, just a job.
GAC

[AllentownJake]

70. Thank you

Believe me if I could wave a magic wand and everyone would get great healthcare I would and I'm willing to listen but i'm not willing to listen when people start throwing angry accusations around.

[Vinca]

32. #1 - Claims are good.

No they're not because data on cost isn't valid and hell will freeze over before an insurance company calls you and suggests a bona fide better treatment plan that doesn't involve them keeping more money for themselves. Cost data isn't valid because it's not unlike a Wall Street ponzi scheme. Insurance companies/HMOs tell providers what percentage of a procedure they will pay. Since the provider doesn't want to give up income and charging the patient directly is like getting water out of a rock, they raise the price of the procedure so after the percentage is knocked off, they're still getting the price they want for the procedure. And so it goes, year after year. (In the late 1960's, when Blue Cross/Blue Shield was a nonprofit, the cost of a normal delivery of a child was about $500 and that included a several day hospital stay. It's now approaching $10,000 and you're lucky if they let you stay long enough to get your shoes off.) My former doctor caught it coming and going. They wouldn't pay him enough for what he was billing on his patients and when he himself was diagnosed with cancer, they only paid a portion of the cost of treating the illness. He went out of business. "For profit" must be taken out of the equation because morally, it doesn't jibe. The only way to make profit is to deny benefits. Denying benefits causes needless suffering and premature death. Fuck the insurance companies and the HMOs.

[AllentownJake]

34. Why does the government use them for Medicare than?

I think if everyone had access to medicare the problem would be alot less.

[supernova]

41. Because the gov't has been privatizing all kinds of services

for the last 30 years.

It's not just Blackwater for "security," though they are the most visible target for that right now.

It's also other types of services that used to be done by civil servants, perhaps even your job 40 years ago.

[AllentownJake]

46. Well I'm doing what I can

in the current system because I care. Some people on here seem to want me to burn in hell for that.

Oh and Medicare always had claims. You can't track cost without them...and than you can't track needs either or budget.

[Vinca]

49. Medicare leaves much to be desired. For starters,

it doesn't cover everything. Most seniors must purchase private, supplemental insurance to cover everything Medicare won't pay. I have a friend whose elderly father was paying a total of $900 a month between Medicare and supplemental insurance and that was before the drug program was enacted. The mishmash of government programs is confusing and difficult for many to understand. The smart thing to do would be to do away with Medicare, Medicaid, the VA, military and any other government-sponsored healthcare program and put everyone on a universal, single payer program administered by the government. One agency, electronic billing at the swipe of a card, etc. Taxes, of course, would go up, but after you take the insurance profits out of the picture everyone would be paying much less overall. I estimate the $12,000 a year policy (last estimate 3 years ago) we can't afford would cost about $3,000 - $4,000 under a government administered plan.

[tpsbmam]

35. You make what I believe is a false assumption that none of this can be

accomplished in (my preference) a single payer universal system.

You can set the system up to capture the same data without having it set up as a "claims" system such as we have now. Looking for "opportunities to treat the person in a more efficient manner" now too often means looking for means to deny coverage, even if the medical needs are very real and necessary. And denying coverage not only means some people will die, it also means more costly healthcare in the future because needed treatment early on has been denied and the problem worsens. Using your example of the ER, decreasing use of the ER and encouraging visiting primary care can be designed into the system. And, importantly, if all of us have access to regular healthcare, ER demands will decrease as people don't have to rely on the ER for non-emergency treatment. We happen to have a good system to provide basic healthcare to uninsured/low/moderate income people where I now live (Asheville, NC area). It's far from perfect -- if you're diagnosed with most types of cancer you're pretty much screwed if you can't afford treatment and don't have medicaid/medicare (true for many people without insurance). But the health department assigns primary care physicians for basic care, walk-in non-emergency care, and more. Area specialty physicians also volunteer hours and provide free care for most most specialties. That hasn't been true for many other places I've lived -- often the ER was the only option open to people -- if there were free/low-cost/sliding scale fee clinics, they were often jammed to the point there was no guarantee a sick individual would be seen, closed on weekends (as our health department here is) sending all of those people to the ER if they feel they can't wait until Monday). I can easily envision in my area a system designed to cover weekend non-emergency healthcare -- one place I lived had triage to shuttle people to the ER or to their lower-level non-emergency clinic. It served to provide weekend care when most docs weren't open and saved the ER for true emergencies. That could be done with our current system or with universal single-payer care. Though the ER is most definitely overused, it's not always the fault of people who go to the ER, it's too often the fault of the healthcare systems we've set up.

Other posters on this thread are right -- adding the third party administration costs FAR more. Look at other countries that have universal single-payer healthcare. Their administrative costs are FAR lower than ours under our current system. The "business interest" that we now have receive benefits from denying coverage. If they are profit based, their first obligation is to their shareholders, not to their clients. And one can certainly look at the obscene profits some have made while they increasingly deny coverage, in addition to the obscene money made by their CEOs and other management level employees. Just because the medicaid and medicare systems are currently inefficient (their administrative costs are still way lower than business-based costs) doesn't mean that the system can't be redesigned effectively.

I HATE the American healthcare system -- its broken in large part BECAUSE of what you're advocating. I WANT to pay taxes to have ALL Americans covered, but I don't want to pay taxes to pay for unnecessary costs, which I believe is what you're system would end up costing taxpayers. And I sure as shit don't want to pay taxes to support private, for profit businesses that have already helped fuck up our healthcare system.

That said, I've moved a lot and have a couple of great HMOs. One of them when I lived in Chicago did, in fact, assign me a case manager. I have a chronic, disabling illness (MS) and I'd never had that happen before -- I was a little skeptical when the manager first called me -- I worried that it was a way to reel in my coverage. I couldn't have been more wrong -- my case manager was FABULOUS and a total sweetheart. She made sure I got what I needed (and I did need what I got), including a scooter for which I didn't pay a cent. So I've had some very good experiences with insurance companies. (BTW, BC/BS was the absolute worst -- when I was first diagnosed with MS, it was done after batteries of tests, multiple visits to a variety of docs, etc. It took BC/BS ONE FUCKING YEAR to pay me back for the $10,000 I had to fork out for all of that, and they only did so after my attorney father intervened. This is after paying them a fortune for about 5 years for individual coverage.) There is no reason you couldn't use the case manager system for more complex cases under a single-payer system -- based on my experience, it'd be an efficient use of taxpayer money. People don't have to be given absolutely everything they "want," but providing good healthcare would in the long run save money. Believe me, I know MANY people with chronic illnesses who have limited access to healthcare and end up in ERs and with hospitalization for problems that could have been avoided if they simply had more access to regular care.

[global1]

36. A Lot Of Cost &Time Goes To The Administration Of HealthCare....

there needs to be standardization of forms. All forms from whomever administers healthcare must be the same. Not like it is now where each insurer has their own forms; their own set of rules; their own layer of administration. This simplification would save a lot of time, energy and cost for the providers as well. Think about all the marketing/advertising expenses that these insurers have to promote their plans. Look at all the cost that would be saved if all were doing the same thing. Layers of administration dollars would now flow to care versus selling and how to minimize care for the insured.

I agree with your concept of 'utilization management'. There needs to be a better way of getting a person to the type of care that they will need and not burden an Emergency Dept (ED) with coughs/colds and minor problems. As pharmacies are interspersed throughout the communities - why not let the pharmacy be the entry point of the system - the first stop for the potential patient. If it is something that can be treated on an OTC basis - the pharmacist - maybe even a nurse working in the pharmacy recommends/treats - based on a set protocol. If it is more serious (again based on a protocol) the patient gets sent to a primary care physician. Physician treats patient. If physician can't treat because and patient is in need of a specialty physician - the patient gets moved along to the specialist. ED's are used for more serious problems - accidents, breaks, etc. We would have to do some training of the masses to let them know what constitutes heading right to a ED. Emphasis of the system should be on wellness and prevention. More health training should be given in schools. I recently heard Elizabeth Edwards speak about healthcare and she had a wonderful idea about the utilization of schools in the community. Schools are expensive buildings to maintain - yet they are utilized just a short portion of the day and the year. Then they are shuttered up until the next school day or school year begins. She posited that schools should be utilized to their fullest in the community and be the manned by nurses that can also serve as a first line of contact for healthcare. Being that they are in every community - people would know where to go - and this would be non-threatening and easy.

With better access to healthcare - entry points - pharmacies, schools vs. MD's offices and ED's - maybe that would relieve some of the wait times and burdens placed on physicians and triage health personnel.

We need to stress more exercise - maybe reinstate PE in schools. Better eating habits. Better living habits. Again - emphasis on staying healthy and wellness.

A great deal of the overutilization of the Emergency Rooms has to do with people not being educated to the system - not knowing what to do or where to go.

I don't really think it is difficult and too costly to make some minor to moderate changes in the system - to make it work better for us.

We shouldn't feel sorry for the insurance company employees. They will be needed to administer this system - so they wouldn't be losing their jobs. Complete standardization of the administrative aspects of healthcare would simplify things for everyone - insurance companies included.

Of course their are other things that need to happen on the provider side to make things safer. We also need to stop the epidemic of 'medical errors' that are hurting and killing people and costing the system money due to increase patient stays because a healthcare worker made a mistake - be it a doctor, nurse, pharmacist, lab tech, etc. This includes computer order entry for physicians; utilization of barcodes all the way up to patient bedside to prevent drug errors - actually more use of computerization technology to prevent errors. Couple with that the hospitals have to practice good Infection Control throughout to minimize or eliminate healthcare acquired infections that increase length's of stay for patients or cause the patients more problems than they had before they came to the hospital. Simple things like washing hands and wearing gloves and good housekeeping could save the system millions upon millions of dollars.

Bottom line - this is not the time to flame any ideas. We all need to input our ideas so that we can come up with the best way to manage health. We call our system an 'healthcare' system - yet - it is more designed now as an 'illness care system'. We need to change that and we need to encourage everyone to get involved in making this change.

[AllentownJake]

37. I like you

You actually made me think instead of going crazy.

In our grocery store there is a nurse practitioner and that is the type of reform I think your talking about.

[supernova]

63. This is the kind of thinking we need more of.

A comprehensive look at the way the entire system works together.

[LeftishBrit]

39. A partial form of this has been tried in the UK, and frankly damaged our health service badly.

The Thatcher government introduced the so-called 'internal market', where the GPs became fundholders purchasing provision of health services from the NHS Trusts, who provide and manage services. This supposedly introduced 'competition' and 'efficiency'. The system was tweaked by New Labour, but fundamentally remained the same. At the same time, hospital management was put more into the hands of professional managers, and less in the hands of doctors and matrons.

In fact, what it did was to cause health care to be run more like a private business and less like a public service. This meant that profit and savings have often become more important than optimum patient care. E.g. the problem of MRSA and other hospital infections has been increased by outsourcing of cleaning services to the cheapest organizations, often not trained in hospital work; and by 'efficient' use of beds meaning relative crowding, and rapid turnover that can interfere with thorough cleaning.

Any universal health care is better than no universal health care; but health isn't a business, and needs to be run by people whose primary interest is in patient care, rather than in costs and profits.

[AllentownJake]

47. You guys were lucky

WWII allowed you to see working together is a good idea. Probably bombs falling on the rich and poor did that to you.

We aren't getting to where you are overnight.

[LeftishBrit]

80. Fair point.

[redqueen]

85. HR 676 is ready now.

It has how many co-sponsors already?

Yes, it has problems. Any system would. It's the best, most prepared solution we have, and it would solve a lot of problems.

No, it won't happen overnight... but muddying the water with "what ifs" is counterproductive IMO.

Enough delay... enough excuses.

[bread_and_roses]

48. People don't use the ER as primary because no one is "tracking" them...

they use it because they don't have health care insurance and can't afford preventive or even routine sick care. Surely you cannot be unaware of this? And surely we can find a way to effectively track an individual's use of health care other than a "claims" system - the current function of which is to deny as much care as possible to maximize profit. And the HMO's are no different, and why you think they are mystifies me.

What is the purpose of your elaborate construct other than to keep profit in the equasion? And what is the point of that? To keep the insurance industry and big Pharma happy? They've done such a GREAT job, right? Including up to, I believe I read, 30% "administrative costs - some efficiency. And you think they should still have a hand in our health care when they have given us the worst health outcomes at the highest cost in the Industrial West?

[AllentownJake]

50. Listen

We have people under insurance who have a PCP and still go to the emergency room. Sometimes it takes a nurse to visit them to find out why. Alot of times its language alot of times is they had a bad experience with the DR and didn't realize they could switch.

I want a system where costs are tracked. My idea for denials and appeals is that it is totally taken over by the government however, again that idea on here is outright blasted because it isn't single payer which I have news for everyone...we aren't getting with Barack.

I'm not as socialist as everyone on here. I am pretty socialist. I want equal opportunity not equal results. I want everyone to have a minimum level of health care and I want everyone to have a free education. Sorry if I'm not liberal enough.

[bread_and_roses]

75. So your proposal is ideological, not - as you presented - "practical"

Of course there is still a need for medical case managers, but various ignorance, fear, etc is not the main reason that people use the ER in place of a Primary. The main reason is that they lack insurance and can't afford health care.

What is the definition of "a minimum level of health care?" What on earth does "equal opportunity ot equal results" mean in the context of health care.

Your "practical arguements do not stand up to scrutiny and are undermined by both the performance of the for-profit system and the experience of other countries with single-payor. So we end up with an irrational "preference" for a for-profit system, based on nothing.

[AllentownJake]

78. That is a logical argument

and I'll accept that.

I believe that if you have a 2% of survival and your 80 its ok not to treat based on cost unless you pay for it and that is what I'm talking about.

[redqueen]

86. "an irrational "preference" for a for-profit system, based on nothing."

:thumbsup:

[global1]

87. How About A System Where Patients Are Tracked Vs Costs?.....

I just sent a package from Chicago to Dallas, Georgia. I used United States Postal Service and I requested the package be tracked. I was able to input a number in the USPS website and see date, time and place of the package all the way up to delivery. It sat for 9 days in the post office that I dropped it off to. Once it left that post office it went to a central processing point in the Chicago area where it sat for 3 days then to Atlanta where it sat for 2 days and finally to the local post office in Dallas, Georgia where it arrived in the a.m. and was delivered to the final destination that afternoon. I even called the USPS to find out why it wasn't moving from the original post office - which after I called - it moved.

The point being is that I was able to watch the package travel that distance and see where the bottlenecks were and see the progression through the system and jump in and effect the system if things bogged down.

Why can't we track patients and their problems the same way? Give them a number when they enter the system. Find out how they progress through the system? Find out if they over-utilized or miss-utilize the system. Find out if the providers are miss-utilizing the system or scamming the system.

If we find patients that are not utilizing the system correctly - someone can go in and educate the patient. We could begin to develop a database to determine the average amounts of time to treat a certain problem.

Now I know that there are extenuating circumstances with each patient and some may take longer to flow through the system - but maybe by seeing how a patient flows through the system - we can begin to develop methods of controlling costs as well. The emphasis here is on the patient/healthprovider relationship - not initially on controlling costs. But if we learn more about what works and what doesn't - maybe this can ultimately help us control costs.

I admit that this is a 'wild ass' idea - but if we can educate people - both patients and providers - as to the best way to utilize the system - maybe we can get a handle on costs as well.

I also hear about Medicaid fraud and abuse and I laugh. We have the technology at are fingertips to prevent this fraud and abuse - credit card companies use it on a day to day basis - yet we don't utilize the same technology that can prevent this fraud and abuse.

AS an aside - I pay $1903 every 2 months to BC/BS for my health insurance. I am self-employed and this is my reality. I try as much as I can to keep myself healthy (live right, eat right, exercise) so as not to utilize this insurance as I am concerned that if I start utilizing it - the premiums will go even higher.

On the other hand - I know people that are in and out of emergency rooms, doctors offices and hospitals at the drop of a hat. These same people don't take care of themselves. They overeat and are obese. They smoke. They overindulge in alcohol. Dress inappropriately for weather and always have colds. They don't practice good hygiene - on self or in their homes. And when they do seek and get healthcare - don't change their practices after they are treated. These are the people that are causing my health premiums to go up. I am paying for their lack of common sense. I resent that.

We need to find better ways of working with these patients and better educate them on the proper utilization of the system. I know too many of them are set in their ways and we may not be able to change their behaviors. That is why we should start early - in grammer schools and continually educate and provide good health and hygiene and patient education.

[supernova]

91. Well, most major hospitals have patient numbers already

I have a very low patient history number at Duke. I've been a patient there since the early 60s. And my history can fill boxes. :P

But when you are hospitalized there, you get your very own UPC code. :P Everything that happends to you and is connected to you is entered with that UPC code: med orders (from the robotic pharmacist), radiology and other lab work, the cast that you need to be made.

So some of that is already being done. I think it's fine and does cut down on errors.

[AllentownJake]

93. Claims are just tying procedures to patients

Its helpful for research and determining what equipment you would need to buy, doctors you need on staff, etc.

You can reform the claim system but if you have a procedure and a patient and it is tracked that is a claim.

[moc]

52. I hate to say it, but you come across as incredibly naive.

By way of my background, I'm a professor at a school of public health. Health care management is not my area of specialty, but by virtue of working in the public health arena (including a close affiliation with one of the largest publicly funded hospitals in the country), I have some knowledge of how the system works.

Where you come across as naive is your assumption that "utilization management" is all it would take to reduce inappropriate ER use. Why do you assume that those who are using the ER for routine medical care have any other source of health care at all? The root of the problem is lack of health insurance or (even if one has health insurance) not having access to affordable care. For example, there is a severe shortage of providers who will take Medicaid. Therefore, having Medicaid insurance does not equate access necessarily.

The problem with our current system is that it is set up in a way that insurers are motivated by NOT providing care and by minimizing their risk. A single payer system could go a long way in reducing administrative costs (which are exhorbitant in the private pay portion of our health care system) and increasing access to all Americans. Sure, utilization management has its place, but without insuring access to all, it's pointless.

[AllentownJake]

54. It's a big challenge

Is getting people who get covered to stop going to the ER.

Just saying.

[supernova]

61. People would naturally stop using the ER

if they had a regular MD office to go to for routine needs.

Cuba, poor as they are, have an MD office, seemingly on every corner.

Again, I think the emphasis must be on providing the most enriching patient experience possible. That will naturally lead to more cost containment as people find their right levels of care for their needs.

[AllentownJake]

72. The Doctors are a problem as well you know

As well as the lawyers.

Reform is going to be a tough bullit for everyone.

[supernova]

84. Some docs are a problem

Not all of them.

Those that genuinely care about their patients' welfare mostly support some version of UHC. There are some who are in it for the $$$ and white lab coat prestige but they are not that prevalent. It's too damn hard to get there.

Lawyers are sometimes necessary because some docs, because they are human beings, sometimes behave badly, even at work.

[AllentownJake]

89. so you'll acknowledge that some bean counters

actually care as well than :-)

[supernova]

92. When you are a hammer

every problem looks like a nail.

:P

[northernlights]

94. damn those pesky doctors

they take on loans the size of a hefty mortgage, go to school forever, work impossible hours and schedules, come to work no matter how horrible the weather, are sneezed on, coughed on, puked on and bled on, and so are daily exposed to some rather nasty, virulent pathogens...and then dare to expect to be reasonably paid for what they do.

Unlike administrator and beancounter gods who sit behind their computers, weather permitting of course, and oh so heroically...control costs. :eyes:

And we wonder why so many doctors decide to specialize in elective plastic surgery for the super-wealthy...just sayin'

[AllentownJake]

95. Yes every last Dr. is a hero

and every last accountant is a villian.

I've had some good doctors and I've had some terrible ones in my life.

[supernova]

99. Accountants have their place

but overall

It is the patient who needs to be satisfied first; healthcare workers second, to make sure they have clean, safe places to work. then accountants last.

We're talking about priorities here.

[AllentownJake]

100. In no where did I say I wanted to be satisfied first

and you realize if the Govt takes this over difficult decisions will be made based on budget about those 1% survival cases for the over 70 crowd and my mother a nurse who is about to retire and is 63 is the biggest advocate of those decisions being made.

[FreakinDJ]

81. Self Serving Trype

[AllentownJake]

90. We are all guilty of that sometimes

[Warpy]

83. Not a flame, but bean counters and cost cutters aren't very good

physicians. Oh, everybody needs to make sure there isn't waste of resources and equipment down to the last 2x2 sponge, but cost cutting has gone far enough that hospitals are now very dangerous places for both staff and patients.

There simply aren't enough people to do the work. Labor is allocated per a parsimonious "patient care hours" actuarial table that makes no allowance for emergencies and admissions. Housekeeping staff has been cut so far that cleaning is cursory and MRSA is becoming nearly epidemic.

Cookie cutter health care doesn't work on real people. Real people progress more quickly or more slowly than the tables say they will. Wounds have their own timetables. People require different dosages of pain control for different lengths of time.

As for sending chronic ER abusers to family physicians, that's a great idea in theory. However, people with no access to health insurance and who are shut out of HMO systems find the barriers to such physicians insurmountable. That sore throat won't be seen for about a month, if then, long after it's turned into pneumonia or worse.

The only answer to the mess known as US health care is to eliminate the profit motive at the insurance level and make it truly universal. Without the bean counter leaning on the physician as gatekeeper and shutting out people who truly need the care, perhaps we can focus on delivery of care instead of profits to shareholders. Without the need to pay cadres of people to deny care, we might actually start to deliver it.

Cost cutting as the focus of the health care system has vastly outlived its usefulness. We need to develop a sane system in which people who are sick can see a doctor. Period.

[supernova]

88. Thank you Warpy

for saying so succinctly what has been so frustrating for me about this thread.

'bean counters and cost cutters aren't very good physicians'

You know the old saying, "when you are a hammer, every problem looks like a nail."

However we design a new HC system, cost cutting should NOT be the primary focus because that will just lead to more stratification of care.

[Hippo_Tron]

101. That's where the long wait times to see a specialist come in

Because if there's no gatekeeping and everybody is insured then there will be far more demand for the specialists than supply. That isn't necessarily a reason not to have universal health care, but maybe we need to be talking about why we have too few doctors as well.

[Warpy]

104. Specialists through HMOs are generally overloaded

The last time I had insurance was the mid 80s. It took me three and a half months to see a specialist even when I had well documented disease that needed care.

Waits are nothing new. Most specialists want referrals from primary care physicians or emergency physicians. That's not going to change, either.

Your concerns are ill founded.

[supernova]

106. Because they keep access restricted

There are limited spaces every year at medical schools across the country. And you could argue it is artificially tight to keep demand and salaries high.

another component of UHC will be medical education and making sure we graduate enough MDs every year, GPs as well as specialists. And nurses.

[uppityperson]

96. In my 32 yrs as a nurse, I've seen a lot of changes.

My first job was on a medical floor of a hospital in a SW city. 1/2 the beds were people waiting for state/fed funded nursing home placement, waiting for beds there to come available. They could not get kicked out of the hospital, but did not need hospital care. There were minimal beds opening up every month at nursing homes that took such patients, since reimbursement was much lower than private pay.

Then there came a change and insurance companies, I think started by medicare, made a list of what they would pay for what conditions, based on averages. If someone were to have a gallbladder issue, there were specific things that would be authorized, be paid for. If they ended up in the hospital for surgery, they could stay only 3 days, then were discharged since "on the average" that was what was authorized.

So there came a lot of people not getting the care they needed, since "on the average" actually equaled "if everything went absolutely right and this was the only isolated thing going on with the person". Which most of us know was wayyyyyyyyyy too simplistic since usually people have other things going on.

A business sprang up of figuring out how to deal with the regulations, how to get people the care they needed. How to manipulate the numbers, how to seek out those tiny little bits so a person who was oozing after surgery, who was not healing as fast as they "should" could continue to get care so they didn't get WORSE, and end up back in the hospital in worse shape. There were lots of public health/visiting nurse businesses that started during this time, trying to help.

Don't forget, though, that Insurance Companies are there to MAKE MONEY, not help anyone stay healthy. One of the older people I used to visit regularly as a nurse had lung issues and I would do checks for that, then help fill out Medicare forms as this person was ready to give up, sell their house to pay for their healthcare since the forms were so confusing.

I agree, that some people take advantage of the system. But I also see insurance companies NOT wanting to pay for the preventive care, or for all those interacting health issues that drive people to the ER.

"If we managed utilization managment better the emergency room can go back to what it is meant to be a triage center and not a free health clinic. Utilization management is also good for drug treatment and serious illness treatment. You want the best care possible and you want it in the most efficient way possible. I agree. One of the things I would like to see is a group/business managing healthcare but not having conflict of interest issues with financing health care.

If a company can make money by making things more difficult for those they insure, that is wrong. If a company can make money by charging patients huge amounts, that is wrong. There needs to be some sort of review of charges, but people don't fit into tidy little holes with only 1 thing wrong at a time. There needs to be flexibility and there needs to be focus on preventive health care.

My local docs are concerned since this last yr their business has dropped off. They aren't concerned about not making money, but that people are waiting longer and coming in sicker since they can't afford to pay, or deductibles if they have insurance (and the # insured has dropped).

[Cleita]

105. I just dropped one of my doctors, a specialist who Medicare pays for.

I needed her to get a prescription I need, but since I can no longer afford the medication even with insurance, I saw no reason to keep her on as there is nothing she can do for me right now other than renew my prescription that I can no longer buy. I wonder how many other people have dropped their doctors as well for the reason that they can't afford the treatment and medication?

[Cleita]

98. No flames. You are on the right track but need to educate yourself further.

Single payer universal health care would solve those problems that you present. Single payer means only that the government collects and distributes health care dollars to various private practices and hospitals. So you have your claims situation intact. Single payer means everyone gets a card that admits them to any doctor or hospital. So all your ER patients who are using it as a clinic can go to a doctor or clinic and bypass the ER. Single payer controls cost by coming to fee agreements with the private sector doctors and hospitals for basic health care on a yearly a basis. It's also able to operate on a 3% administrative cost margin as contrary to 25% average for private health insurance. About buying politicians that's a separate issue that needs to be addressed by real campaign finance reform. Click on the links in my signature and they will lead you to John Conyer's website, who is advocating for extending an improved Medicare for all and to the Physicians For A National Health Plan website, who have all the information you need in one place including studies and articles about it. Also, single payer works spendidly in all the countries that use it. Don't believe insurance company propaganda regularly put out that claims otherwise.

[donco6]

103. I'm convinced so many of our problems relate to . . .

SIZE. The distance a large organization creates between the patient and those doing the accounting.

I work in accounting in a small school district. I'm in classrooms probably once a week. I'm in charge of all operations, as well as performing arts and class sponsors. I get to see the people we serve, and it makes a huge difference when we start our discussions about cutting this or that program. I know the people. I know the kids. I'm confident that we do everything possible to figure out an alternative before we start slashing.

I'm not sure that happens when things get isolated. In a big corporation, it's far too easy to deny a claim, or cut a service, because those making the decisions don't actually SEE the people they're impacting.

I know that making things larger is supposed to increase efficiency. But it also turns a BMW factory into a Yugo factory. If you want Yugos, I suppose you can say you're successful. But when it comes to health, I'll take the BMW.

[Cleita]

107. I used to do medical billing myself, but I'm not an accountant.

I worked with an accountant though. I came to the conclusion that national health care was what was needed even though it would have put me out of job. Doing billing to one payer would have simplified the procedure considerably as there would have only been one form and one set of rules and payment schedules to deal with. Instead of physicians having to sort through a roster of companies trying to find out what they would and wouldn't pay for, there would have been one answer. Many of us would settle for Yugos instead of nothing. It's not really humane of you BMW people to demand that for yourselves and exclude those who can't afford BMWs. We need a basic and comprehensive health program for everyone. Then you can go buy insurance for the extras that you want beyond that, just don't deny us what we need.