Thoughtful Conversation About the US Healthcare System

FWIW, my PCP doesn't take insurance. I pay him a fixed fee every year and can see him as much as I want. He can spend 45 minutes or an hour with me if the need arises. None of this "15 minutes and on to the next". Things like blood tests are $50.

His "staff" consists of a receptionist and a RN. No need for 3 or 4 people coding and doing billing. He has full admission privileges with Mass General.
 
Toocold said:
The result has been an explosion of pseudo-physician roles like Nurse Practitioners and Physician Assistants, and as a result, PCP positions are becoming more marginalized.
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Is that good or bad? I can see arguments both ways. FNPs can provide basic services in communities where there are too few physicians.
 
audreyh1 said:
In order to be a medical school you have to be accredited by the AMA, so the AMA has considerable influence over what any medical school does.

Why do they limit admissions? Simple, it’s to maintain a shortage of doctors. It has nothing to do with quality, deliberately limiting supply. Means higher prices for physicians. Also higher prices for medical schools I imagine.
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To be fair, the undue burden of medical malpractice and overheads outside control of physicians (someone mentioned 30% admin cost) calls for higher price for doctors. It is chicken and egg problem when comes to doctors.
 
Toocold said:
The result has been an explosion of pseudo-physician roles like Nurse Practitioners and Physician Assistants, and as a result, PCP positions are becoming more marginalized.
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Which is a win-win for consumer and doctors alike. Doctors get to earn some money (more like RE brokers earns from agents) from PA/NPs because they need to be working under a doctor's supervision. Lower cost and faster appointment times for consumers.
 
marko said:
FWIW, my PCP doesn't take insurance. I pay him a fixed fee every year and can see him as much as I want. He can spend 45 minutes or an hour with me if the need arises. None of this "15 minutes and on to the next". Things like blood tests are $50.

His "staff" consists of a receptionist and a RN. No need for 3 or 4 people coding and doing billing. He has full admission privileges with Mass General.
Click to expand...
This another way market has been responding: bypass insurers altogether. I have a physician friend who abandoned his standard medical practice and is about to start a subscription-based medical care (office under construction).
 
I think we need to divorce health insurance from employment. All health insurance should be individual health insurance, like home, car, and most life and disability Insurance.

It makes no sense that your health insurance should get upended when you change jobs or that you should need to restart deductibles if you change jobs in the middle of a year.

A couple examples.

DD is currently a SAHM and was pregnant when DSIL was recruited to a new job that didn't provide employer health insurance for the first month of employment. Since they were uncovered for that month and COBRA form his prior employer was hugely expensive the gap in employer provided health insurance put them in a bind with respect to monitoring DDs high risk pregnancy. If health insurance was individual that problem would be avoided entirely.

DS does some job hopping and has occasional gaps in his employment. So he has to go from employer provided health insurance to ACA, and then a few months later switch back to employer provided health insurance. It's a sizeable hassle that is unnecessary.

Employees would have more freedom to pick plans that meet their needs rather than a small number of employer provided options. Employers could still provide financial support as a benefit to support recruiting employees via HSA contributions and you could make health insurance a qualified medical expense from a HSA. It makes no sense that Medicare Part B and Part D premiums are qualified but Medicare Supplement insurance or individual health insurance for those not yet Medicare eligible is not qualified.

Anyway, it's time to blow up the funding mechanism. Employers would be relieved to get rid of the burden of providing and administering employer provided health insurance.
 
MTB4me said:
As long as the US healthcare system is profit-driven, costs and quality of care will not improve. It's no more complex than that.
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neihn said:
That's right and it will not change.
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Every company is profit driven. That doesn't mean that they don't care about their cost to the consumer or the quality of their product. While it's true that there are cost issues and the quality could always be better, it has nothing to do with being profit driven. The problem is the payment system. By having insurance and government between the provider of care and the consumer, the system is not reactive to market forces. I would argue that situation is far more related to the problems we face versus their profit driven mentality.
 
MichaelB said:
The insurance driven compensation rates are distorted, with specialists being paid much more than primary care, which drives more graduating physicians to specialize and leaves even fewer primary care.
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When you say "insurance" above, do you include Medicare and Medicaid as insurance?
 
Surewhitey said:
Yeah, DW works for the 5th highest compensated insurance CEO company... $16.5 mil in 2023 is definitely not trivial. #1 got ~$27 mil. Hard to imagine anyone's worth based on them having the same # of hours in a day as the rest of us.
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Yeah, it's hard to believe that a CEO would be compensated at the same level as pro athletes or entertainers (those that are also at the top of their food chain). Why, for heaven's sake, would a CEO be paid as much as a MLB starting pitcher or the lead singer of a boy-band? Makes no sense. 😏
 
youbet said:
Yeah, it's hard to believe that a CEO would be compensated at the same level as pro athletes or entertainers (those that are also at the top of their food chain). Why, for heaven's sake, would a CEO be paid as much as a MLB starting pitcher or the lead singer of a boy-band? Makes no sense. 😏
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Well, it sure isn't due to the insurance company's CEO's legions of adoring fans/customers.
 
robls said:
Here are the top 20 countries with the highest health insurance costs and average life expectancy as of 2024 according to CoPilot. USA is not even in the top 20 for life expectancy, but number 1 in costs per capita.
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Life expectancy isn't all about health care. US culture has some really bad aspects leading to very short lives. I don't want to get us off track on that issue.
 
MichaelB said:
Yes indeed
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DW and I are both on Medicare. Well, MA for her. We recently had outpatient procedures that resulted in hospital + doc bills exceeding $100k each. Medicare approved less than 25%. We were both surprised that a outpatient procedure could generate that high a bill and that the insurance negotiated payable amount was such a small percentage.

Neither of us owed anything after insurance, so we just shrugged and went on. There does seem to be a real disconnect between insured patients and pricing or negotiated/allowed payment levels.

I wonder if that contributes to our seemingly high medical costs?
 
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Lorenzo said:
Well, it sure isn't due to the insurance company's CEO's legions of adoring fans/customers.
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Maybe it is. Aren't most insurance companies publicly held? If the CEO is delivering favorable financial results to the stockholders, they might adore her/him!
 
youbet said:
Neither of us owed anything after insurance, so we just shrugged and went on. There does seem to be a real disconnect between insured patients and pricing or negotiated/allowed payment levels.

I wonder if that contributes to our seemingly high medical costs?
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Yes, I’m sure. This has been noticed for a long time. Our system has created a crazy situation where medical bills are extremely inflated because they know they will normally only get a small amount of it approved.
 
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marko said:
FWIW, my PCP doesn't take insurance. I pay him a fixed fee every year and can see him as much as I want. He can spend 45 minutes or an hour with me if the need arises. None of this "15 minutes and on to the next". Things like blood tests are $50.

His "staff" consists of a receptionist and a RN. No need for 3 or 4 people coding and doing billing. He has full admission privileges with Mass General.
Click to expand...
If you have tests or procedures that are significant in cost, do you submit them to insurance yourself? Or do the labs and hospitals who perform the tests bill your insurance?
 
Toocold said:
The result has been an explosion of pseudo-physician roles like Nurse Practitioners and Physician Assistants, and as a result, PCP positions are becoming more marginalized.
Click to expand...
My PCP has a PA and a NP in her office. When I need a short notice appointment, I usually will be offered same-day or next day with the PA. I find the PA does a better, more through job than the PCP does anyway and prefer them. Ha!
 
Jerry1 said:
Every company is profit driven. That doesn't mean that they don't care about their cost to the consumer or the quality of their product. While it's true that there are cost issues and the quality could always be better, it has nothing to do with being profit driven. The problem is the payment system. By having insurance and government between the provider of care and the consumer, the system is not reactive to market forces. I would argue that situation is far more related to the problems we face versus their profit driven mentality.
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Market forces don’t work in health care for 2 reasons. First, as Kenneth Arrow (Nobel Prize economist) pointed out in his 1963 paper (here), market forces work when information is symmetric (buyers and sellers know about the same). With health care physicians have knowledge that patients don’t, and that puts the provider in a position to exploit and take advantage.

Second, healthcare in the US has insurers, providers and consumers each looking to maximize their utility at the expense of the other 2. Any 2 parties can reach an agreement that optimizes their share, but the 3rd will always be left out.

As long as there are 3 conflicting interests and information is asymmetric, market forces will be unable to find an optimal point. Something other than market forces is needed.
 
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The reality in the US is that we do not have a healthcare system but rather a health insurance system. No matter how it is spun, health insurance is simply not health care.

Many people advocate for "Medicare for all" which would no doubt provide more access and negotiating prices of drugs would help, but administrative costs would soar and like Medicare we would continue the health insurance industry rather than a healthcare system. We would be simply throwing a lot more money at basically the same solution we now have but with possible broader benefits.

A system like the British NHS would be the best solution, but that would mean nationalizing all the hospitals, ambulance services, paramedic services, etc. and negotiating a service contract with the Medical associations to establish a fee for service and service obligations for any doctor that wanted to participate!

That of course is dead on arrival and nothing more than wishful thinking.

I cannot see a solution, especially considering our political and capitalistic environment.
 
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