Let's make a list of current healthcare inefficiencies

[intent]

I've seen so many threads on this topic, on this and other forums, but I've yet to see a thread where any community attempts to make a mostly comprehensive list of the inefficiencies in the current U.S. healthcare system. Plenty of mention of inefficiencies, but no specific listing.

Of the forums I frequent, this seems to be one of the most mature and level-headed, and so the most likely to be up to the task of compiling such a list.

No attempts should be made within this thread to address how to solve an inefficiency - this is just a list. Also, please don't dispute any inefficiency someone else lists - at least not in this thread. This should be viewed as a first step brainstorming list, free of editorial comment. I propose that, if we can make a list, we then start another thread where we tackle suggestions for addressing the listed inefficiencies.

Who knows, maybe someday someone in Washington will visit this forum, and the bill that eventually wins the day and saves our country will be titled, "The Early Retirement Dot Org Healthcare Reform Act."

I'll begin:

Current healthcare inefficiency:

The cost of health care is typically not known until *after* it is consumed.

 

[crazy connie]

Consumers are not savy consumers directly related to subsidy by insurers or subsidy by gov't

Drug costs R&D subsidized by US

Breakdown of family unit feeling responsible to assist elders

Ignorance of common sense in new parents

Direct drug advertising to consumers who demand latest and greatest feel better now pills

 

[samclem]

- Employees having to rely on their employers to buy this one particular type of insurance

- Only indirect linkage between the individual receiving the service (the patient) and the payer.

 

[ERD50]

Excellent idea.

- Lack of nation-wide competition across insurance companies.

- Ins cos are exempt from some anti-trust regulations (as I understand it).

-ERD50

 

[plex]

- Most hospitals will not ever give you a price quote, nor do they need to

- For dental work, you can actually get price quotes fairly easily, and then can look in horror at the differences in prices between those who accept insurance, and those who do not. (Hint: Those who don't accept insurance actually usually charge much less than what your insurance+you pay combined).

- (Real example) When I had dental insurance, I did not care if my fillings cost $600, as long as I did not need to pay it. When I didn't have health insurance, I got (what actually turned out to be) better fillings for $120 each from a different dentist, who accepted cash. And I am an extremely cost conscious person, imagine what it is like for those who spend money like water.

 

[samclem]

- Cost shifting and resultant billing overhead
From: The uninsured and Medicare patients
To: Those privately insured, the few cash customers, and taxpayers

- Extremely complex billing system

- Lack of commonality of procedure coding between insurers

- Tort and liability issues (these costs are apparently not as high as some people claim, but they are a problem, along with the 'defensive medicine" costs they engender)

- Lack of an efficient market for individual health insurance.

- The blurring of the line between providing medical care and medical care insurance. Outside of the health insurance biz, "insurance" is something a customer buys to protect against a rare but catastrophic calamity. In the US, we expect medical insurance to cover routine or at least anticipatable costs. For example, the normal costs of labor and delivery are anticipatable.

- Lack of good, easily accessed consumer-friendly information on the quality of the healthcare sold by competing providers. I can find better information on car tires and mechanics near my home than I can about which doctors and hospitals do the most open heart surgeries and what their results have been.

 

[ERD50]

PROBLEM - An emphasis on low deductibles and low co-pays as being "good coverage".

Some background: Many people could benefit from a high deductible policy - pay lower premiums and pay the routine things out-of-pocket (which makes us more aware of the costs). There is overhead for all these small charges, and we all just end up paying for it. We should have ins for risks we cannot afford - not for routine expenses. Yet, few of us have the option of a high deductible policy through our employers.

A friend had an explanation for this trend, and he may be right. Ins cos like to sell low deductible policies if they can, because it is more work for them so they can charge more (just like a car company would rather sell you a luxury car than a stripped down compact). And since employers have used health care benefits to attract talent, the more complete the coverage, the "better" it sounds. So the two feed off of each other, but we all really end up paying the bill.

-ERD50

 

[Midpack]

Not exactly inefficiencies, more challenges/issues. But someone did post a great list IMO on an earlier thread, I liked it so much I saved it (I should have saved name also to credit whoever it was):

lifestyle (obesity, smoking, drugs)
high cost and profit for intermediaries (insurance)
excessive profit for some product and service providers
administrative burden (millions of microplans)
high charges for specialized services
forced use of expensive specialized facilities for routine medical needs (emergency room)
multiple regulations around the country
punitive legal awards
diagnostic overuse (expensive tests even for routine matters)
treatment overuse (especially end of life)
excessive unproductive labor vs technology

 

[calmloki]

We recently changed insurance to Kaiser Permanente - hated doing so, as I had about a 20 year history with my private doctor, not a Kaiser doc. However, after a few months on Kaiser I'm very impressed - my doc used to refer me to a cardio guy here and a vascular guy there and a shoulder surgeon another place - all of them people he trusted and I'm sure quite good. Every time I went to a new doc the deductible and copay would eat me alive, to say nothing of driving to random distant spots and back while not feeling tiptop. Each place had a new multi-page form to fill out, records had to get shuttled around and were often delayed or missing when needed. With Kaiser it's nearly all in house - visit my primary, go down the hall for a blood draw from a row of people who only draw blood at purpose built stations, go down the hall for vaccinations, ditto x-rays, ditto echocardiograms - even on-site outpatient surgery. And - SHOCK - they do use computers. WELL! I can email my doc and get a response back, email for prescription refills, when I go from the primary to the blood draw to the echo they all have all my records right at hand online. Things are done efficiently and quickly, negligible waiting, I feel I've had good care, and other than the copays there has been no out of pocket expense. If Kaiser is an example of the savings possible via computerized common records and a single payor I'm a big fan. My prior health-care was expensive and far more time consuming and, I think, more like normal health-care today.

 

[samclem]

If Kaiser is an example of the savings possible via computerized common records and a single payor I'm a big fan.

Why do you associate the top-notch service you are getting from this private company with a single payer system? It sounds like this service would be available from any well-run private HMO.

I'm glad you found care you are happy with, and that you benefitted from having options. Super. I'll bet if there were no other options, if Kaiser were the only system in the whole country, if there was no competition at all, and that if you had complaints there was no higher regulating authority outside the entity providing your care (all attributes of a government single payer system) that things might be less satisfactory.

 

[calmloki]

Why do you associate the top-notch service you are getting from this private company with a single payer system? It sounds like this service would be available from any well-run private HMO.

I'm glad you found care you are happy with, and that you benefitted from having options. Super. I'll bet if there were no other options, if Kaiser were the only system in the whole country, if there was no competition at all, and that if you had complaints there was no higher regulating authority outside the entity providing your care (all attributes of a government single payer system) that things might be less satisfactory.

The computer use seemed familiar - sorta like the touted savings from same touted by our President. I only have my experience with health care, and if Kaiser is similar to a single payor system - oh wait, it is - I'm saying it works real well. Re those health care options you mention, I was pretty much forced away from my doctor when the gal's company changed insurance plans.

 

[Gotadimple]

The fallacy that high deductibles plans are the best solution for all. Result: those who can afford the premium, sometimes can't afford the cost of health care --> seek care at emergency rooms, or not at all --> cost of ER care born by the tax payers as they can't pay.

The belief that quality of care is provided by health insurers who examine claim records, as a demonstration that they can control quality of care, when all they do is reimburse providers.

Medicare's focus on fraud of the largest kind, rather than focusing on the smaller providers, in an effort to demonstrate to Congress that they can catch fraud.

 

[samclem]

I only have my experience with health care, and if Kaiser is similar to a single payor system - oh wait, it is - I'm saying it works real well.

I think we are using the term "single payor" differently. Medicare is a government "single payor" system (for all Americans over 65) and yet it has all the inefficiencies you associate with your former plan (uncoordinated care, high admin, etc). We could all have plans just like you have now without the government getting involved as the "single payor"--just as you do right now.

Re those health care options you mention, I was pretty much forced away from my doctor when the gal's company changed insurance plans.

Yep, it's crazy. "My wife changed jobs, so now I have to change my doctor." How dumb is that?? We definitely need to break the employer/insurance link. The biggest political probem is that workers continue to believe that their private insurance costs are coming out of their employer's pocket, when nothing could be further from the truth. The employees pay for every dime of inefficient, wasteful insurance coverage that employers buy. I guess it's like "I didn't have to pay any taxes, in fact I got a refund!"

 

[ERD50]

The fallacy that high deductibles plans are the best solution for all.

Who is saying that "high deductibles plans are the best solution for all"? I haven't heard that. Earlier, I said it would be good for many, and I would like to see it as an option. I'd even consider an escrow so there is no doubt I could pay.

No attempts should be made within this thread to address how to solve an inefficiency - this is just a list. Also, please don't dispute any inefficiency someone else lists - at least not in this thread.

But, perhaps we should get back to the OPs request.

-ERD50

 

[ziggy29]

1. Consumers of the product are shielded from the true cost of the product so there is little incentive or ability to be "good consumers" of health care.

2. The silly link between employment and health insurance. Employer-provided group insurance as the "norm" creates market distortions that have made the individual health insurance market largely inefficient, noncompetitive and dysfunctional.

3. Lawsuit abuse which leads to "defensive medicine" and the extra costs it puts on the system -- not to mention the judgments themselves and the cost of malpractice insurance.

4. Different people pay different rates for the same procedure depending on their insurance coverage (or lack thereof).

5. American pharmaceutical consumers subsidize the rest of the world's drugs because they bear a disproportionate cost of the R&D due to caps placed on their pricing in other countries.

6. Too many people seeking routine care in the emergency rooms, many of whom are uninsured since they can't be immediately turned away from the ER by law.

7. Differences in profitability and salaries leads to more specialists and not enough general practitioners.

8. Differing state requirements on health insurance can lead to many different versions of the same "product" offered by the same company, requiring additional bureaucracy and administrative costs.

I'm sure I've forgotten a few.

 

[Caoineag]

How about not being able to know the cost effectiveness or plain effectiveness of a treatment procedure? A lot of procedures are currently done without any knowledge of effectiveness, major side effects, etc.

Medical insurance pays for messups by doctors and hospitals when any other service provider would be required to fix their mistakes for free.

Hospitals breed infections which requires more medical intervention (related to the one above).

 

[eridanus]

Some providers make additional money for each test that's performed, which encourages additional tests if someone else (i.e., the insurance company) is willing to pay. (Re: The New Yorker story and Brownsville, TX hospitals v. Mayo Clinic)

 

[growing_older]

It is very difficult or even impossible to know the cost of anything in advance. Even simple things like durable medical equipment purchased through insurance have multiple prices and often cannot get quotes from anyone until after "purchased"

The rent-to-own schemes for durable medical equipment. My insurance will only "cover" a wheelchair if I rent it for 13 months. After that it's mine. However I could have bought one for about 2 months worth of payments.

Inflated "list prices" which no insurance ever really pays. But uninsured people have to pay these effectively subsidizing the insured.

Ability of insurance companies to arbitrarily (and sometimes retroactively) decide what treatments are covered and which aren't. Occasionally putting even "insured" people in the position to pay the inflated "list price"

No coverage for existing conditions. Means there is incentive to avoid care that would make insurance more difficult in the future. Means there are people who are locked in to current employment because once they leave that insurance group they will be "uninsurable"

I only really want to buy insurance for big expenses. Since insurance is only really available through employers, I have no ability to shop for plans. I take what the employer signed up for or I get nothing.

 

[deserat]

The computer use seemed familiar - sorta like the touted savings from same touted by our President. I only have my experience with health care, and if Kaiser is similar to a single payor system - oh wait, it is - I'm saying it works real well. Re those health care options you mention, I was pretty much forced away from my doctor when the gal's company changed insurance plans.

Calmloki - Kaiser is an integrated healthcare system - they own the docs, the insurance and the facilities/nurses/other employees. And, they tend to be careful about what they outsource. In the case of single-payor, the ownership is not total as described above. It is to Kaiser's advantage to focus on prevention as it drives down the costs of more critical care by catching things early, etc. The incentive is different - too much hospitalization costs too much - now some may argue that drives them to skimp, but if you are covered, you are covered. Kaiaser has changed their business model over the years due to government regulations and business drivers, however, the underlying premise is similar--once you are in Kaiser, you are in Kaiser.

I agree with the many posters in that being an informed consumer is nigh impossible in our healthcare system - I can find out more about a used car than I can in the ability/excellence/lack thereof of a clinician and/or the costs for a procedure, which makes me a poor consumer and can cause inefficient (read poor doctors/poor procedures) producers to stay in the market too long.

I know that some people do not like Kaiser (it is a bureacracy), however, the drivers for profitability are different than from a segmented point of view (insurance only or clinicians only or facilities only).

 

[Gumby]

1. Consumers of the product are shielded from the true cost of the product so there is little incentive or ability to be "good consumers" of health care.

2. The silly link between employment and health insurance. Employer-provided group insurance as the "norm" creates market distortions that have made the individual health insurance market largely inefficient, noncompetitive and dysfunctional.

3. Lawsuit abuse which leads to "defensive medicine" and the extra costs it puts on the system -- not to mention the judgments themselves and the cost of malpractice insurance.

4. Different people pay different rates for the same procedure depending on their insurance coverage (or lack thereof).

5. American pharmaceutical consumers subsidize the rest of the world's drugs because they bear a disproportionate cost of the R&D due to caps placed on their pricing in other countries.

6. Too many people seeking routine care in the emergency rooms, many of whom are uninsured since they can't be immediately turned away from the ER by law.

7. Differences in profitability and salaries leads to more specialists and not enough general practitioners.

8. Differing state requirements on health insurance can lead to many different versions of the same "product" offered by the same company, requiring additional bureaucracy and administrative costs.

I'm sure I've forgotten a few.

9. Lack of effective, centralized, computerized health records leads to repeated and unnecessary lab tests and diagnostic procedures.

10. Lack of portability caused by the employer healthcare model leads to inefficiencies in the labor market as people take suboptimal jobs solely for the health care.

11. Allowing physicians to take an ownership interest in testing facilities (e.g. - labs, MRI, xray) leads to unnecessary and expensive tests.

12. Incredibly expensive medical education programs that force doctors to charge high prices just to pay off their student loans.

13. Ineffective coordination of prescriptions given to a single person that can lead to adverse drug interactions or render certain medicines useless.

14. Failure to focus on preventive care, including proper diet and nutrition and an attendant over reliance on after the fact medication (think cholesterol control).

 

[ziggy29]

10. Lack of portability caused by the employer healthcare model leads to inefficiencies in the labor market as people take suboptimal jobs solely for the health care.

Yeah, this is one I've certainly harped on here in the past, so I'm surprised I didn't mention it again. It's sad to think about how much entrepreneurial spirit -- and economic value-added -- has been lost because some people with both great ideas and the ability to execute a solid business plan never did so because they were chained to Megacorp's health insurance, not to mention that their dreams are stifled by feeling chained to those benefits. I sort of mentioned it by calling out the silly linkage between health insurance and employer, but this is another consequence of it which I didn't list.

 

[Martha]

To add just one thing to Gumby and Ziggy's lists:

15. Outmoded and inefficient medical procedures. For example, from a 2008 CBO report:
Variations in health care are often most dramatic when there is uncertainty about
what kind of treatment to administer. For example, it is clear that aspirin should
almost always be provided to a patient upon admission to the hospital for a heart
attack, and there is very little variation in that practice. However, there is significantgeographic variation in the use of imaging and diagnostic tests, and it is often unclear when those services generate useful information or how frequently they should be provided.
Similarly, admission to the hospital for a hip fracture is always indicated, and admissionrates for people with that injury show little variation; but much less of a consensus exists about back surgery, and the related admission rates vary much more widely.
Overuse of supply-sensitive services and differences in social norms among local
physicians seem to drive regional approaches in the use of innovations and treatments.
Some regions appear more prone to adopt low-cost, highly effective patterns of care, whereas others are more prone to adopt high-cost patterns of care and to deliver treatments that provide little benefit or are even harmful.

* * *
However, even among elite medical centers, there is
significant variation in cost. Among the UCLA (University of California, Los Angeles)
Medical Center, Massachusetts General Hospital, and the Mayo Clinic (St. Mary’s
Hospital), for example, composite quality scores are very similar (81.5, 85.9, and
90.4, respectively). Although the Mayo Clinic scores above the other two, its cost per beneficiary for Medicare clients in the last six months of life ($26,330) is nearly half that at the UCLA Medical Center ($50,522) and significantly lower than the cost at Massachusetts General Hospital ($40,181). Uwe Reinhardt, renowned professor of
economics at Princeton University, asks, “How can it be that ‘the best medical care in the world’ costs twice as much as the best medical care in the world?”2
So how much could all this amount to? Researchers have estimated that nearly 30 percent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas.

http://www.cbo.gov/ftpdocs/93xx/doc9384/06-16-HealthSummit.pdf

 

[Midpack]

Interesting, but where is this going? Just asking...

 

[Martha]

Interesting, but where is this going? Just asking...

Nowhere. We have no lobbying power.

 

[ziggy29]

Interesting, but where is this going? Just asking...

I just think it's interesting to see what we think the problems are, and contrast that to what the politicians are doing. I think it's interesting and positive to note that we have been creating a list that is fairly "multi-ideological" in that these are problems that one side or the other is advocating for or against, yet it looks like a lot of us (as opposed to the folks in Washington) can see that neither side has all the answers to what needs to be done.

And yet both sides act as if they know all the things that need to be done, even when both sides are tainted with partisan agendas and the desire to protect their pet constituents. We collectively have no such taint, and it's showing in the rather non-partisan list of problems we've documented -- some from column A, some from column B and a little bit that's not in either column, if you will.