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They've been at this for over 60 years and are still wrangling with how to do it best. I can only imagine what's going to happen here in four years... http://www.nytimes.com/2010/07/25/world/europe/25britain.html?_r=1&partner=rss&emc=rss
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The "communications between GPs and consultants...have become fragmented and distant". The only choice is to make the GPs the consultant's boss? Who can be that stupid.
Not long ago many of the big insurance companies in the US gave primary care doctors a kickback at the end of the year for not referring to specialists. They made thousands of dollars for handling cases that should have been refered to specialists. I'm not implying that all PCPs were abusing the system, but a lot were. I saw a patient that was referred from the ER. I sent a letter to his internist who sent it back to me with "I did not order this consult" written on it.
Even now many insurance companies will have a list of their Super Doctors (or is that Lebowski scholars) based solely on how little money they spend on their patients. I have never been on one of those lists and I don't even think I practice defensive medicine.
Your primary care doctor is the "gait keeper" and as such should not have a financial interest in patient referrals.
Oh, God, I have to shut up about this. I'm just glad I got to Cleveland before my income was cut 30% - no consult codes, thank you very much. Medicare started it but the privates are following suit. The joke in the office is just give the new Medicare patient $15 and call it even. I can't stop taking Medicare as some doctors are doing because my mom is on Medicare and I can't turn away someone just because the system sucks. Hey, they might be someone's mom too.
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Well, Sam, we can all hope we have at least one doc in our lifetime like you. My PCP is a good and caring doc too. It so sucks that good docs like yourself have gotten caught in the fray of politics. I TOTALLY agree with you. I remember those days when I had to BEG for a referral and ended up not getting it 2 out of 3 times! I just read an article last week about how the big 3 insurers are 'experimenting' in anticipation of the health care bill going into effect, where they will offer a very small list of doctors who are in-network and pay NOTHING for doctors outside of the network, instead of a reduced fee to out of network docs. This is tantamount to having PCPs being the gatekeeper because there will be almost no doctors on the "limited list" so no one to really refer the patient to in-network--of course unless the patient can afford to pay 100% for an out of network doc. All of this to supposedly control the cost of health care, regardless of what happens to the patients? Whatever. Insurance companies really do run this country.
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I've lived in a country with socialized medicine. It was to my understanding that no "insurance company" was involved as middlemen for this and rather that it was the STATE that financed medical intervention. Now the state did not really pay the doctors a whole lot and sometimes doctors would complain that the state was not paying them enough and in that way, it would prompt the patient to 'tip' the doctor as to hand him over some extra cash for his efforts (or for more attentive treatment). However, that 'extra' amount was still 'affordable' for a patient to offer on his/her own.
Also, with the socialized medicine, it does not preclude doctors from having a private practice meaning a practice that is not under umbrella of the state. For example, there was an internist who did acupuncture and all of his patients were self paying. Thing is his self pay prices were not really in excess of what an average person (covered by the state) could afford.
In my experience with socialized medicine, it can also open up opportunities for doctors wishing a 'private practice' but still provide basic medical care for all.
Can hardly walk. Need hip replacement.
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Excellent plan...a tip jar right next to the please turn your cell phone off sign. The multitalented Miss J not only helped me look better she's a career consultant.
Thanks for the kind words D. The sad thing is there is nothing in my sample closet to make me feel better. JK.
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Not sure why, but they call the UKs plan 'socialized' medicine. Wiki explains it this way: Quote:Socialized Medicine:
Jonathan Oberlander, a professor of health policy at the University of North Carolina, maintains that the term does not mean anything at all.[10] Exact definitions vary, but the term can refer to any system of medical care that is publicly financed, government administered, or both.
The original meaning was confined to systems in which the government operates health care facilities and employs health care professionals.[10][11][12][13] This narrower usage would apply to the British National Health Service hospital trusts and health systems that operate in other countries as diverse as Finland, Spain, Israel, and Cuba. The United States' Veterans Health Administration, and the medical departments of the US Army, Navy, and Air Force would also fall under this narrow definition. When used in this way, the narrow definition permits a clear distinction from single payer health insurance systems, in which the government finances health care but is not involved in care delivery.[14][15]
More recently, a few have used the term more broadly to any publicly funded system. Canada's Medicare system, most of the UK's NHS general practitioner and dental services, which are all systems where health care is delivered by private business with partial or total government funding, fit this broader definition, as do the health care systems of most of Western Europe. In the United States, Medicare, Medicaid, and the US military's TRICARE fall under this definition. The US plan that was passed is definitely not socialized, it's anti-social as far as I'm concerned.
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Well, enough of the patients did do that and the doctors would often tell patients that the state did not pay them (enough) for their work. But the system was also one where the state did not 'profit' either from a doctor and it was not a thing where they let insurance companies to be middlemen to profit either. People seem to think US is adopting "socialized medicine". But if it did that, they would have to give all those for profit insurance companies the boot.
Can hardly walk. Need hip replacement.
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Well, from my experience; "socialized medicine" refers to your tax money (often a Value Added Tax for consumer goods) or the money they might with hold from a pay check going to the government to be SPECIFICALLY USED toward financing medical care for the people. Like instead of the money taken by the government going towards something like "Military", it goes towards "Medical". Different countries have different ways of organizing socialized medicine though. I think in Norway (or Sweden?), a big chunk of taxes is taken from the pay check to go towards it. Sometimes these 'taxes' are DIRECTLY aligned with CONSUMER GOODS. Like for every consumer good you buy, there is a federal tax on it. In that way, 'who can afford the most consumer goods' is directly proportional with who pays the most taxes and a lot of them go towards medical care. Luxury consumer goods get taxed more. They figure if one can buy a Lear Jet or luxurious furs etc, those people should pay more in what they call a higher "Value Added Tax"; VAT. DCNGA wrote:Not sure why, but they call the UKs plan 'socialized' medicine.
Wiki explains it this way:
The US plan that was passed is definitely not socialized, it's anti-social as far as I'm concerned.
Can hardly walk. Need hip replacement.
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I do not think the US plan that passed is socialized medicine, we may be better off if it was in some ways. I think 'nationalized' is probably a better choice of words for the UK system. In 2000, this is how natioanlized health plans around the world were ranked by WHO (they no longer rank, 2000 was the last time they ranked): 1 France 2 Italy 3 San Marino 4 Andorra 5 Malta 6 Singapore 7 Spain 8 Oman 9 Austria 10 Japan 11 Norway 12 Portugal 13 Monaco 14 Greece 15 Iceland 16 Luxembourg 17 Netherlands 18 United Kingdom 19 Ireland 20 Switzerland 21 Belgium 22 Colombia 23 Sweden 24 Cyprus 25 Germany 26 Saudi Arabia 27 United Arab Emirates 28 Israel 29 Morocco 30 Canada 31 Finland 32 Australia 33 Chile 34 Denmark 35 Dominica 36 Costa Rica 37 United States of America 38 Slovenia 39 Cuba 40 Brunei 41 New Zealand 42 Bahrain 43 Croatia 44 Qatar 45 Kuwait 46 Barbados 47 Thailand 48 Czech Republic 49 Malaysia 50 Poland 51 Dominican Republic 52 Tunisia 53 Jamaica 54 Venezuela 55 Albania 56 Seychelles 57 Paraguay 58 South Korea 59 Senegal 60 Philippines 61 Mexico 62 Slovakia 63 Egypt 64 Kazakhstan 65 Uruguay 66 Hungary 67 Trinidad and Tobago 68 Saint Lucia 69 Belize 70 Turkey 71 Nicaragua 72 Belarus 73 Lithuania 74 Saint Vincent and the Grenadines 75 Argentina 76 Sri Lanka 77 Estonia 78 Guatemala 79 Ukraine 80 Solomon Islands 81 Algeria 82 Palau 83 Jordan 84 Mauritius 85 Grenada 86 Antigua and Barbuda 87 Libya 88 Bangladesh 89 Macedonia 90 Bosnia-Herzegovina 91 Lebanon 92 Indonesia 93 Iran 94 Bahamas 95 Panama 96 Fiji 97 Benin 98 Nauru 99 Romania 100 Saint Kitts and Nevis 101 Moldova 102 Bulgaria 103 Iraq 104 Armenia 105 Latvia 106 Yugoslavia 107 Cook Islands 108 Syria 109 Azerbaijan 110 Suriname 111 Ecuador 112 India 113 Cape Verde 114 Georgia 115 El Salvador 116 Tonga 117 Uzbekistan 118 Comoros 119 Samoa 120 Yemen 121 Niue 122 Pakistan 123 Micronesia 124 Bhutan 125 Brazil 126 Bolivia 127 Vanuatu 128 Guyana 129 Peru 130 Russia 131 Honduras 132 Burkina Faso 133 Sao Tome and Principe 134 Sudan 135 Ghana 136 Tuvalu 137 Ivory Coast 138 Haiti 139 Gabon 140 Kenya 141 Marshall Islands 142 Kiribati 143 Burundi 144 China 145 Mongolia 146 Gambia 147 Maldives 148 Papua New Guinea 149 Uganda 150 Nepal 151 Kyrgystan 152 Togo 153 Turkmenistan 154 Tajikistan 155 Zimbabwe 156 Tanzania 157 Djibouti 158 Eritrea 159 Madagascar 160 Vietnam 161 Guinea 162 Mauritania 163 Mali 164 Cameroon 165 Laos 166 Congo 167 North Korea 168 Namibia 169 Botswana 170 Niger 171 Equatorial Guinea 172 Rwanda 173 Afghanistan 174 Cambodia 175 South Africa 176 Guinea-Bissau 177 Swaziland 178 Chad 179 Somalia 180 Ethiopia 181 Angola 182 Zambia 183 Lesotho 184 Mozambique 185 Malawi 186 Liberia 187 Nigeria 188 Democratic Republic of the Congo 189 Central African Republic 190 Myanmar
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I don't think so either.
Can hardly walk. Need hip replacement.
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((sam)) I didn't know the private insurers were also cutting fees. Not much to add to this thread except I just found an interesting doc blog a couple days ago http://dinosaurmusings.wordpress.com/ <- she is an older family practice doctor. I don't know if she has posted about Medicare/ insurance yet, but she probably has somewhere.
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Sam, what are your thoughts on the ACO proposal: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20Seems dicey to me, but maybe I just don't fully understand the ramifications. Seems like a combined incentive to limit referrals and services. Not sure.
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D, I think your understanding is right on target. The concept of improved "untilization of cost and quality of care" being rewarded (with cash) doesn't seem too horrifying until you realize that the "payers" reward the ACO based on their concept of utiliaztion of cost and quality of care.
We already have quality of care parameters - readmission within 24 hours, falls in the hospital, aspiration pneumonia, etc. You can follow the short list of quality of care measures and be a really bad doctor but be considered to provide high quality of care. How? Avoid very sick patients. Refuse to see the elderly whose risk for all the quality of care markers are higher.
Utilization of cost is simply do less tests and be considered cost efffective. So, yes rationing of care. Insurance companies already do this by denying tests and drugs, requiring preauthorizations on everything and then denying them.
I learned something scary today about the AMA (an organization which I do not support) poll on how doctors are going to handle Medicare (and private) abolition of consult codes. There were the expected - see less Medicare patients, spend less time with Medicare patients, etc. What scared me was that there is an allowance by Medicare that because you are not consulting on the patient when you are a specialist, you are managing and treating them (thus using lower E&M or evaluation and management codes) you don't have to send a letter to the refering pysician. So all this noble sounding reference to Mayo, which does have a great system because they do work together in a very integrated way, is completely opposite of what the real situation is. I don't even have to send a report to the internist who sent the patient to me because I'm not really consulting on him. That was an option some chose in the AMA poll.
Limited refereals, limited choice of pysicians, limited testing, and (what we're not telling you) limited communication between your doctors.
I support healthcare reform. I want the same single party payer that congress has.
Now that you are all bored to tears by me, read the blog m130 cited. I didn't have time to read much of it but it made me laugh so hard I almost wet my pants.
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You're my newest hero, Sam. Got really bad news about my husband's CF today (lungs are failing rapidly, could mean heart/lung transplant). He's always had great insurance (we pay out the nose even in a group policy) that covers his VERY expensive meds and treatments. Now I am pretty sure that before it is all over this will work it's way down to his coverage, sooner rather than later, and we will never be able to have the meds and treatments he needs to live. When he was taking Toby (he can't take it because it damaged his hearing) all of his meds were $30K a month, yes that is $30,000 if insurance had not paid most of it. Even if by a miracle he lives to medicare age, he will die the first six months because we cannot afford the meds he needs to live.
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That sounds heart breaking. Have you looked into ordering the drugs from over seas places or Canada?
Can hardly walk. Need hip replacement.
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Would you actually have to pay $30,000 if you didn't have insurance? On my adderall it says $450 self pay but one month while I was waiting for the insurance to get my student confirmation form I told the pharmacy I didn't have insurance and payed $60. I had the same thing when insurance didn't pay for my stress test, I just called up the Cleveland clinic and ended up paying a fraction of the bill. The prices shown are for the very few who can afford them from my understanding.
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Thanks, Miss J. For now we have coverage and he gets his meds via our insurance. We are just concerned, if his lungs don't give out first, that in a 2-3 years when all of the health care changes start that most of the meds won't be covered. But, at least while he can work and has this job and while the health care bill is not in place (yet), his meds are covered. Even with co-pays, if we bought every medication he has to take, it is around $350 per month for his meds (on insurance). We are even more worried that they'll put us in an HMO and he'll never get his proper referrals to the FOUR different docs he has to see! Our scripts show the amount insurance pays and the amount of our co-pay so I'm guessing the amount the insurances pays (which is less than retail) would be what we would have to pay if we were paying ourselves.
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D, I really hope that this doesn't impact your husbands care. In my state (I'm not sure about the rest of the US) we have a Bureau of Insurance. For some reason even alot of doctors don't know about it. If a patient's preauthorization is turned down I can have a "peer to peer" with a neurologist that works for their insurance company. If they turn me down the patient can appeal to the bureau of insurance, an agency which makes sure the insurance companies are acting fairly. It is the best way I have found to protect my patients rights. Will this remain intact with the upcoming health changes, not sure.
You have informed yourselves about your husbands condition and that knowledge and knowing your rights will be key. I may be naive but I believe that some good will come of this mess. The ignorance of the government ( Medicare part D, thank you George Bush, were you high?), the greed of the insurance companies, the greed of many doctors and the entitlement of many of the insured called for a complete revamping of our medical system. What we had was bad. What we have is worse. What we are getting is unthinkable. Sometimes it is that nadir that causes people to rise up and effect a change in the right direction.
The remaining fear is that the quality of those wanting to go into medicine is dropping and only the fee for service specialties will have quality providers. I really worry about what my primary care doctor will be like when I am a little old lady. Scary times.
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Scary times, Sam. Scary times. I'm afraid the good docs, like yourself, will quit or give up and we will only be left with the docs who got their degrees in the mail (figuratively speaking).
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D, I can't quit. I put myself through medical school and haven't paid off my med school loans yet. I'm going to be the Betty White of neurology. I have absolutely no other marketable skills. I had a friend with a chemistry degree from Princeton whose first job was as a Nabisco cookie taster, so maybe there is something out there for me...
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