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Old 04-12-2011, 08:19 AM   #81
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The only way this would work would be if the hospital and doctors (or someone else) could rule these tests as unnecessary without excessive fear of litigation.
The argument that fear of litigation drives overuse of medical diagnostics is just smoke and mirrors put up by the AMA in order to pass the blame for high healthcare costs onto the law profession. Not a bad strategy given our propensity to distrust lawyers but also not truthful.

I quote here from the report on healthcare costs to Congress:

"...analysis by the Congressional Budget Office (CBO) that used a broader set of ailments found no effect of malpractice tort reform on health spending. It concluded that “[o]n the basis of existing studies and its own research, CBO believes that savings from reducing defensive medicine would be very small.”
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Old 04-12-2011, 08:31 AM   #82
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Aruba50, I don't disagree with some of your obviously strongly-held opinions regarding the many problems with health care in the US. But I'm curious as to why you have such passionate interest in the subject since you apparently 1) don't have to live with the many shortcomings of our dysfunctional system and 2) aren't in a position to vote to change it?

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Old 04-12-2011, 09:09 AM   #83
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REWahoo,

I am Canadian and so therefore am a very close neighbor. I have many American friends in part because I work for a very large American conglomerate. I have always held America in extremely high regard and have the highest respect for it's people's energy, inventiveness and compassion. We are not so very different having grown up together as co-inhabitants of North America. Our values and perspectives are fundamentally the same. I care about this issue because I think that things could be better for my American friends. That's all.
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Old 04-12-2011, 09:11 AM   #84
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Look at any study you can find and you will see that physicians in the U.S. make on average, by far, more than anywhere esle in the western world, including Canada. Anecdotes about one or another's specialities being able to command more outside the U.S. are not useful, relevent or substantial. When you run a private "for profit" healthcare system with virtually no controls on what doctors charge, you will wind up spending a lot of money and some people will die because they cannot afford any of it. That is the American healthcare system.
Looking at just income is meaningless. What are the numbers after you take into account operating costs (insurance, general practice costs, taxes, etc) and educational costs. Also, exchange rates do at the time of the analysis affect the results when making comparisons among countries.

I think you post points out the deficiency in our educational system.
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Old 04-12-2011, 09:12 AM   #85
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REWahoo,

I am Canadian and so therefore am a very close neighbor. I have many American friends in part because I work for a very large American conglomerate. I have always held America in extremely high regard and have the highest respect for it's people's energy, inventiveness and compassion. We are not so very different having grown up together as co-inhabitants of North America. Our values and perspectives are fundamentally the same. I care about this issue because I think that things could be better for my American friends. That's all.
Makes perfect sense. Thanks for your response.
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Old 04-12-2011, 09:27 PM   #86
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What I find very interesting is that America is about the only industrialized western country that does not have universal, government funded medical care.

Having said this, America spends more per capita on health care than most other nations and the growth of health costs in America outstrips those of other countries. This will lead to a disaster. Yet, a careful examination of mortality rates, public heath stats, etc clearly show that there is no reward for this spend. The opposite is true-many countries spend less per capita, less a percentage of GDP, and yet have better health standards.

I do not know if it is the big business medicine, that fact that Americans are forced to spend on average 30 percent more on prescription drugs, the insurance costs, or the costs of administering the publicly funded portions of the program tjat causes this huge disconnect.

One thing that strikes me is that the vested interest groups will continue to influence government-on both sides of the argument-to further their own interests at the great expense of the patients and the the taxpayer.
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Old 04-12-2011, 10:20 PM   #87
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I recommend the Book TOTAL CURE By Harold S. Luft as one possible approach to solving our uniquely American Health Care System Crisis. IT is bold and deeply thoughtful and incorporates unique solutions for America.
Also the book makes a good argument that getting everyone covered (for the main cost drivers) is desirable either as a social justice issue or simply thinking about it from a strictly economic/ smart business standpoint...whether you think people are entitled to certain care as a right or not makes no difference. How this author does it is very interesting.
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Old 04-12-2011, 11:18 PM   #88
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What I see is that according to this data, Dutch and Australian specialists earn marginally more than US specialists and US specialists earn quite a lot more than all the rest. And as you said, US GPs are at the very top.

IMO this data without knowing specialist's efficiency is slightly to not at all helpful. Utilization is a very big factor. If an opthalmologists does 950 cataracts/year, his pay should not be compared to someone doing 150. A heavily hierarchical system that achieves efficient utilization could bring in more revenues to the practice, while at the same time costing the patients and 3rd party payors less. It's the concept of capacity utilization. When througput goes down, costs per unit go up, sometimes a lot.

It is obvious to me that the modern world has outgrown the model that our system (if it can be called that) is based on. Now that clearly does not mean that our system will change, it has successfully resisted change for a very long time and every year that goes by powerful interests are further entrenched.

I don't know if this kind of thing (utilization rates) is recorded cross-country; journalist tend to be satisfied with any story, not necessarily a meaningful one

Group Health, an HMO here in Seattle tends to have surgeons who become specialized in some procedure or small group of procedures-eg. arthroscopic shoulder surgery. And they do a whole lot of this set of operations. Well, you know this, as you live and practice in or near Seattle yourself I believe.Ha
This is definitely true. India has done some incredible work with high volume procedures at substantially lower costs and with much fewer complications. To make it work though you need a large referral base to get the number of patients needed as well as surgeons willing to do the same procedure over and over again. In the US this would mean fewer specialty centers and patients willing to travel further to get their care. You would also need providers willing to work in such a model. I doubt you would find many Cardiothoracic surgeons willing to do aortic valve repairs day in and day out.

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Clearly US doctors are very well paid compared to those from other countries. I do not know how much effect this has on US medical costs which is a more complicated question. But like I said before, I doubt it lowers them.
Addressing how physicians are paid rather than on how much would have a bigger impact on costs and more importantly outcomes I think. Currently procedural specialists skew the income numbers tremendously and are incentivized to, guess what, do procedures. The more procedures the more income. The patients also have some responsibility. Given a choice between lifestyle changes and medications vs an angioplasty what would most want? I'll bet most would choose the latter - especially if their insurance company covers the cost.

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Old 04-12-2011, 11:50 PM   #89
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I have read the report in it's entirety. It clearly disputes your claim that specialists will make more in Canada. It is a report chock full of interesting data that essentially says that while outcomes on average, are no better than other OECD countries, the cost is hugely higher. It acknowledges repeatedly that by nearly any measure, America physicians are paid "substantially" more than their OECD counterparts.

With regards to my "inflammatory" comments on uninsured patient mortality, I would like to draw your attention to the following excerpt from the report "(Americans) were also most likely to delay or forgo treatment because of cost." While this report does not dwell on the fact that the 45 million Americans that have little or no insurance experience shorter life expectancies and poorer health, there are many studies that do. Anyway, this is intuitively obvious and as a physician, I assume that you would acknowledge this.

Finally the report makes the observation that of the OECD nations "only the United States, Mexico, and Turkey have not established
“universal or near-universal coverage.” Not great company to keep. At least it could be said that Mexico and Turkey are economically backward countries and so cannot afford to care for their citizens. There are 45 million Americans that would be better off almost anywhere else.
Please read my post more carefully. My statement only pertained to my specialty, it was not a blanket statement of "all specialists". It is clear you have an ax to grind so I'm done responding to you. But consider this. US physician take home pay (after paying for malpractice and practice costs) amounts to ~10% of the entire health care cost of America. Cut our pay in half and you have saved a whopping 5%. Good luck attracting the best and brightest willing to service $200k of student loan debt and devote the years needed for education and training.

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Old 04-13-2011, 12:04 AM   #90
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What I find very interesting is that America is about the only industrialized western country that does not have universal, government funded medical care.

Having said this, America spends more per capita on health care than most other nations and the growth of health costs in America outstrips those of other countries. This will lead to a disaster. Yet, a careful examination of mortality rates, public heath stats, etc clearly show that there is no reward for this spend. The opposite is true-many countries spend less per capita, less a percentage of GDP, and yet have better health standards.

I do not know if it is the big business medicine, that fact that Americans are forced to spend on average 30 percent more on prescription drugs, the insurance costs, or the costs of administering the publicly funded portions of the program tjat causes this huge disconnect.

One thing that strikes me is that the vested interest groups will continue to influence government-on both sides of the argument-to further their own interests at the great expense of the patients and the the taxpayer.
Don't inject facts into this topic.
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Old 07-28-2011, 07:37 AM   #91
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Update

This update is related to my previous post in this thread:

U.S. Spends 141% More on Health Care

So I move and get a new doctor. The new doctor gives me a prescription that has made the indigestion a lot better but he also became obsessed with my heart. He says he sees/hears nothing wrong but wants me to have a stress test. This time, as I said previously, I complied. So the test results come in and he says that he thinks I had a heart attack recently but that he doesn't see that it did any damage. So now I am in the fee for service endless loop.

So I go for him to discuss the test results. I had just seen him a couple of weeks ago. Most of the time his office was racking up the charges measuring the same weight, blood pressure, etc. that they did a couple of weeks before. By the time I left they had set up an initial consultation meeting with the cardiologist across the street. The cardiologist office called and said he would talk to me and measure vital signs. Isn't this what my regular doctor did two weeks ago and two days ago? Was the second appointment with my regular doctor even necessary when all he really did was charge my insurance to tell me to see someone else, something his office could have done with a phone call? Or why can't the cardiologist just get the vital signs data from my regular doctor and save some money in the "initial consultation"? I'm sorry but it seems to me that if they are as worried as they pretend, all these talky and vital signs meetings would be wasted time and money. Now I guess my insurance will just cover it and I should just be glad that I have it. But, I do wonder if merely having good insurance is adding to the bill.

I expect today's meeting will result in the cardiologist ordering additional tests. I know I'm luck to have insurance but I feel like everyone has a list of things that they can charge for that the insurance won't argue about and they add these to every visit even though the measurements are unrelated to the visit and, if they shared the data, they would have no excuse to repeat them. I guess I think that they could have just looked at the stress test and asked me to come in for an additional test without two doctor consultations in the middle.

Rant over, thanks for listening.
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Old 07-28-2011, 07:58 AM   #92
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Old 07-28-2011, 09:05 AM   #93
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I've been a registered nurse working in health care for over 35 years.
The most expensive thing in health care is the ball point pen in a physicians hand.

I can't even begin to describe the thousands of useless tests, procedures, consults and therapies I have seen prescribed. But....health care is a product, and if you go to where they sell it....they will try and force you to buy top-of-the-line, even when there is no clear advantage to your health.

Call me a broken record, but what I said earlier in this thread is true. Health care providers are counting on our lack of knowledge and a certain level of fear in order to sell us on getting additional tests and procedures.
And when insurance pays for it, we do "shrug" and go with the flow because we aren't sure what else to do. They count on this level of complacent compliance and are not pleased when faced with someone questioning the added value of whatever is being ordered.

I recently experienced this myself. Three weeks ago today I realized I had a detached retina in process. I saw the surgeon that did my cataract surgery within 24 hours, and he confirmed it. He referred me to a retina specialist who saw me within the next two hours, and performed a pneuatic retinopexy with cryopexy in the office. After three weeks of needing to hold my head in an oddly-angled manner, the retina seems to have re-attached and much of my vision is returning.

I have private insurance with a $5000 deductable and exclusion riders on my eyes due to having cataract surgery, and my total hip replacement. This makes me a cash pay patient for this problem.

The surgeon that did my cataract surgery charged me $170 to refer me to the retina specialist. That covers the dilatution of the one eye so he could examine the retina, and the 2-3 mins of his exam. He advertises that he does retina surgery, but I now know he limits it to retina tears that can be fixed with laser. I would have self-referred to the retina specialists if I knew that. Not exactly false advertising on his part......but certainly feels like that when I have to pay $170 cash for something I already knew.

The retina surgery was $4223, which I paid. The contracted rate with my insurance (United Healthcare) is $2940, so it is this amount that goes against my deductable...not what I paid. I am not due a refund of the $1,283 difference because I am self-pay.

At my last visit to the retina surgeon the staff wanted to take a "picture" of my retina. When I explained that I will need to better understand how this "picture" will help my recovery, they tried to say that it was necessary for all patients with retina surgery. When I finally said I was cash pay and wouldn't pay for it without understanding it, they finally said "OK...never mind..." . The surgeon never mentioned it when he saw me.

I am fairly savvy in being able to negotiate within the healthcare system when it's not an emergency situation. But this has been a discouraging episode that only confirms my belief that our current healthcare system is corrupt.
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Old 07-28-2011, 09:39 AM   #94
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Originally Posted by Silver

Call me a broken record, but what I said earlier in this thread is true. Health care providers are counting on our lack of knowledge and a certain level of fear in order to sell us on getting additional tests and procedures.
And when insurance pays for it, we do "shrug" and go with the flow because we aren't sure what else to do. They count on this level of complacent compliance and are not pleased when faced with someone questioning the added value of whatever is being ordered.

I recently experienced this myself. Three weeks ago today I realized I had a detached retina in process. I saw the surgeon that did my cataract surgery within 24 hours, and he confirmed it. He referred me to a retina specialist who saw me within the next two hours, and performed a pneuatic retinopexy with cryopexy in the office. After three weeks of needing to hold my head in an oddly-angled manner, the retina seems to have re-attached and much of my vision is returning.

I have private insurance with a $5000 deductable and exclusion riders on my eyes due to having cataract surgery, and my total hip replacement. This makes me a cash pay patient for this problem.

The surgeon that did my cataract surgery charged me $170 to refer me to the retina specialist. That covers the dilatution of the one eye so he could examine the retina, and the 2-3 mins of his exam. He advertises that he does retina surgery, but I now know he limits it to retina tears that can be fixed with laser. I would have self-referred to the retina specialists if I knew that. Not exactly false advertising on his part......but certainly feels like that when I have to pay $170 cash for something I already knew.

The retina surgery was $4223, which I paid. The contracted rate with my insurance (United Healthcare) is $2940, so it is this amount that goes against my deductable...not what I paid. I am not due a refund of the $1,283 difference because I am self-pay.

At my last visit to the retina surgeon the staff wanted to take a "picture" of my retina. When I explained that I will need to better understand how this "picture" will help my recovery, they tried to say that it was necessary for all patients with retina surgery. When I finally said I was cash pay and wouldn't pay for it without understanding it, they finally said "OK...never mind..." . The surgeon never mentioned it when he saw me.

I am fairly savvy in being able to negotiate within the healthcare system when it's not an emergency situation. But this has been a discouraging episode that only confirms my belief that our current healthcare system is corrupt.
Glad the retina surgery was successful for you Silver. I have a question for you as I have similar insurance deductible and could face same situation down the road concerning payment costs. You said the cash cost to you was $4223, but contracted rate from UH is $2940. I thought one of advantages of HD insurance was getting the insurance discount price for out of cost to you. Did you ask to pay the contracted rate instead of what they charged you? Did you try for more of a cash discount by paying upfront? There appears to be a level of negotiating like buying a car when having high deductibles and paying with cash. I haven't had to do this and fear I might not be prepared for it.
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Old 07-28-2011, 09:44 AM   #95
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...performed a pneuatic retinopexy with cryopexy...
Easy for you to say...

I infrequently get a pain in my lower back/right hip area, that is almost debilitating. Over the years, I've self-diagnosed that something in the sacro-iliac region gets out-of-whack, and it makes nearly any movement excruciatingly painful. I've also discovered that 1-2 days on muscle relaxers stops it cold. My doctor x-rayed me twice for this, but the third time I refused. He reluctantly gave me a script for Flexeril (cyclobenzaprine), which did the trick, as it always does. The first, or even second x-ray I sort of understood, but the third? Now if the muscle relaxant hadn't worked every time, then plan B...

Of course, it's only a $20 copay...
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Old 07-28-2011, 09:52 AM   #96
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Glad the retina surgery was successful for you Silver. I have a question for you as I have similar insurance deductible and could face same situation down the road concerning payment costs. You said the cash cost to you was $4223, but contracted rate from UH is $2940. I thought one of advantages of HD insurance was getting the insurance discount price for out of cost to you. Did you ask to pay the contracted rate instead of what they charged you? Did you try for more of a cash discount by paying upfront? There appears to be a level of negotiating like buying a car when having high deductibles and paying with cash. I haven't had to do this and fear I might not be prepared for it.
I'm with Mulligan on this. Did you pay this upfront without submitting to the insurance first? I've always submitted to the insurance to determine the contracted rate of any procedure, then let them tell me what applies to the deductible and what my payment obligations are after all has been determined. Anything after the $2940 is not your responsibility, but most doctors won't refund it unless you ask for it back.

By the way, I've never been able to get a better or equal negotiated rate paying out of pocket compared to what the insurance co's can get you.
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Old 07-28-2011, 10:00 AM   #97
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By the way, I've never been able to get a better or equal negotiated rate paying out of pocket compared to what the insurance co's can get you.
+1

We've had high deductible coverage for the past 6 years and (thankfully) never come close to meeting the deductible. We always run the bills through insurance first before paying and the contract rate is always significantly lower than the "list price". In general I've seen discounts of 50 - 60% on most services except tests/lab work where the discounts can be as much as 90%.
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Old 07-28-2011, 10:06 AM   #98
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+1

We've had high deductible coverage for the past 6 years and (thankfully) never come close to meeting the deductible. We always run the bills through insurance first before paying and the contract rate is always significantly lower than the "list price". In general I've seen discounts of 50 - 60% on most services except tests/lab work where the discounts can be as much as 90%.
That is more reassuring REWahoo and Dimsumkid, to me, as that is what I was hoping the insurance could provide for me. Hopefully Silver will catch this and respond as I am curious about the differential. I need all the info I can get in this individual market insurance world!
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Old 07-28-2011, 10:15 AM   #99
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That is more reassuring REWahoo and Dimsumkid, to me, as that is what I was hoping the insurance could provide for me. Hopefully Silver will catch this and respond as I am curious about the differential. I need all the info I can get in this individual market insurance world!
I don't think this part of insurance is any different from company provided insurance or Medicare. If you get a negotiated rate on a procedure, that's all you're obligated to pay. Several years ago, some providers tried to collect over and above the negotiated rates. It's a pressure tactic they use to pressure you into paying the extra costs that they're not supposed to get. They'll routinely send you a bill for the full amount, hoping you'll pay it. That's one of the reasons why you pay for health insurance. Just wait it out until it all gets settled through the insurance company invoices, when in doubt, talk to your insurance company and see what's due out of pocket and ignore the provider's separate billing.
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Old 07-28-2011, 11:03 AM   #100
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I definitely would hold out for the insurance company to have their way with the provider. On every policy I've had (PPO) they stipulate that participating providers have agreed to the negotiated amount. Since I always go to participating providers, I will not pay anything more than the insurance company tells me. If the doctor's office tries to charge me more, I am on the phone talking with not only them doctor's office, but the insurance company. Normally any pricing issues is a coding problem. I have never paid more for a service than was expected or negotiated.
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