Advocacy: Reminder

Dori I understand your beef with insurance but you are not acknowledging that it is a solution of sorts to a fundamental problem - the disconnect in healthcare between the supply and demand curve.

Normally supply and demand are controlled by price - if we want more of something (demand) we’ll pay more and in response more will be made (supply). This is not what happens in healthcare - we all want optimal care - MRIs for headaches - but we can’t afford that level of care. The value provided by insurance is that it connects the supply and demand curves. Insurance decides if something is a good value. The obvious problem with this approach is that the insurer values all sorts of things that the person who needs medical care does not value or values less.

A single payer system has the same problem - supply/demand curve disconnect - but responds differently. I’d call it rationing but that word carries baggage … making societal value decisions. Take dialysis the closest thing to single payer in the US. MSP rations program access and the three day a week standard rations dialysis dose and resources used. Fundamentally reimbursement determines what is supplied and therefor, rations what is delivered. Again think of the dialysis unit - at the start of the year the renal administrator (RA) knows or is given the average revenue per treatment, from that number it is the RA’s job is to figure out how use that money - staff ratios, consumable choices, etc. if reimbursement goes up or down it will change what is possible. (note - whether the provider is for or non-profit does not matter. Profit is a cost of doing business all business have, it’s an expense, an overhead expense that varies between organizations. It is typically less of an expense in non-profit organizations.)

If cost was not a constraint would incenter dialysis look the same? Why not use ultra-pure dialysate, silicon instead of PVC, more staff per dialyzor, high end artificial kidneys, unlimited frequency? Reimbursement implies the answer - they are not worth the price. Who decides what is worth the price in ESRD? I don’t know or no one does in the US and in other countries? I don’t know - isn’t it true that in the existing single payer systems it is hard to do more than the US standard unless there is a clear financial advantage from a global cost perspective? Does that by itself lead to clinical progress?

The problem is the goal. Our goal is not to save money, it is to save human potential. We want people (ourselves) to not only exist we want to live the lives we were meant to live. That is a big harry audacious goal, something we can strive for but realistically it’s not achievable in the near term. But we can work towards our goal.

Break medical care into three buckets - acute, chronic and preventative - and cover them in different ways. Preventative (and what use to be called public health: disease education and surveillance) fits with the single payer model, all services are free to the consumer - in fact you might be rewarded for healthy lifestyle habits. Preventative costs money but it delivers value to the entire system and moves us in the direction of the goal. The government does a lot in the name of protecting us - encouraging the development of healthy habits and looking for early signs of disease would do more then many of the government’s other efforts.

Chronic conditions could be covered by Medicare Plus (Medicare for all with no MSP). The difficulty in setting a reimbursement rate that does what you want it to do and the difficulty of monitoring the quality of care has to be understood when designing the system. I don’t think we want to enact a system that freezes medical care at the level of 2007, just as dialysis care seems to have been frozen in 1972. And I don’t think we want to monitor care through unfunded mandates to the states. If we could do a good job with this piece it would make everything else easier. I think this piece of the healthcare system is where the federal government should focus in the near term. This is the area of healthcare most ripe for reform.

This leaves acute and my personal heterodoxy. I’d favor a high deductible health savings account insurance scheme tied to FICA and/or access to federal benefits besides a pension. If the other pieces worked then this piece would be a smaller problem each year making insurance a smaller part of the system over time. Making some future reform easier to enact.

I agree that there can be a disconnect between supply and demand–but strongly disagree that insurance is needed to forge this relationship. In a good medical system (as in, say, France), doctors decide when an MRI is needed for a headache and when it isn’t, based on the history and symptoms of the patients they see. They are trained medical professionals. I don’t want administrative folks making $10/hr. at an insurance company, who have no medical training–or even nurses, who are not doctors–making these decisions based solely on economics.

Who decides what is worth the price in ESRD? I don’t know or no one does in the US and in other countries? I don’t know - isn’t it true that in the existing single payer systems it is hard to do more than the US standard unless there is a clear financial advantage from a global cost perspective? Does that by itself lead to clinical progress?

There are perverse incentives and disincentives built in to the way we do reimbursement in the U.S. For example, as you know, the 3x/week “standard” is a historical accident, left over from experiments done in Seattle in the '60s when there were equipment shortages. When they tried dialysis one day/week, people died. Twice a week, and they died. Three times a week, most of them lived. They stopped there. When the ESRD Program began in 1973, the 3x/week stuck–but Medicare never said how long the treatments must be. So, over time, they got shorter and shorter. If we changed reimbursement to pay more for longer dialysis, we would get more dialysis. If we changed Medicare to eliminate the wall between Part A and Part B, we would create incentives to keep people healthier and out of the hospital. Either or both of these things could be done even w/o a single payer system.

Break medical care into three buckets - acute, chronic and preventative - and cover them in different ways. Preventative (and what use to be called public health: disease education and surveillance) fits with the single payer model, all services are free to the consumer - in fact you might be rewarded for healthy lifestyle habits…

Chronic conditions could be covered by Medicare Plus (Medicare for all with no MSP)…

This leaves acute and my personal heterodoxy. I’d favor a high deductible health savings account insurance scheme tied to FICA and/or access to federal benefits besides a pension. If the other pieces worked then this piece would be a smaller problem each year making insurance a smaller part of the system over time…

I like your plan a LOT, Bill. It gets rid of private insurance for preventive and chronic disease care (and puts it back in the only spot where it makes any sense), and may be more doable than one single payer system for everything. Now, if we could just figure out a way to get you in charge of health care. Have you considered running for President? :smiley:

I’m not saying it is a good idea, I’m saying something/someone has to play the role. In France care is limited structurally - fewer MRI machines. Costs can be non-financial too - time. How many doctors do you have to see before you receive the MRI in France? In the US who but insurers could make the decision under the current system? We have many MRI machines and any doc can write the order.

But in systems that do the things you suggest there is still no 4th day treatment offered incenter - why? Does looking at global costs lead to clinical progress? As I say I think you could create a better system but it would have to acknowledge the stifling impact of any program. The historic accident in dialysis was only identified in retrospect (except for some Charra, Scribner, et al). If we expand federal coverage - Medicare Plus - what new historic clinical accidents will become clinical standards of care?

There are enough people running but I would be happy to lend my perspective to a number of politicos. The point of view of someone with two weeks to live is missing from the healthcare policy discussions. Maybe that should be my healthcare blog name - Two Weeks to Live.

So-called “managed care” was supposed to impose those kinds of structural limits, but failed when it meant that A). It left them less competitive in the marketplace, B). It was counterproductive to the MRI companies’ (and others’) intent to market their devices, and C). Doctors were paid by the visit/procedure–so they were motivated to prescribe more MRIs. Having doctors on salary so their medical judgments are not influenced by marketing would also structurally limit these sorts of overuses.

If we expand federal coverage - Medicare Plus - what new historic clinical accidents will become clinical standards of care?
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Well, we’ll never know that until we try a new system. It’s not possible to predict everything, and it’s not possible to fine-tune systems through legislation or even policy. At some point, we just have to jump and plan to make corrections. It’s the not planning ahead for corrections that has gotten ESRD into so much trouble. If someone had thought of annual inflation updates in 1972 (or even imposed them in 1982 when the composite rate went into effect), we probably would be doing 4th treatments now, given the medical evidence against a 2-day treatment gap. The reason we’re not is strictly costs–and the Medicare Part A/B wall that keeps hospitalization separate from dialysis treatments.

Awhile back I mentioned about it…I said that dialysis center are getting BIG money from the Private Insurance holders which in turn covers more than what needs to be covered. On the other hand, are Private Insurance holders getting better service than those on medicare? I don’t think so…

Extending coverage from private insurance holders might just be the answer…

So, are you saying that since people with private insurance get no better care even though their insurance is paying more, that using their health insurance could be the answer to keeping dialysis facilities profitable?

Would you feel the same way if you had an employer plan with a lifetime maximum benefit?

I’m going to paint some worst case scenarios.

Say you either have a low (even $1 million is low) lifetime benefit. Say you have ESRD and you have diabetes or you have a complication here and there. Say you take several medications every month and you are hospitalized a few times (few patients aren’t hospitalized for something). Every doctor you see has a contracted rate with your insurance for 2-3 times Medicare rate every time you see one. Your pharmacy bills your insurance for the contracted rate for your medications. You have a few x-rays and scans along the way that the provider(s) gets the contracted rate of 2-3 times Medicare’s allowed rate. How long do you think it would take to use up your employer group’s lifetime benefit so you have no coverage besides Medicare?

What if you do daily dialysis 5-6 days a week? Your dialysis clinic’s contracted rate with your insurance is 2-3 times Medicare’s rate for every dialysis treatment you get. Because you’re getting twice the number of dialysis treatments and your employer plan pays 2-3 the amount Medicare pays weekly or dialysis, your charges for dialysis alone would add up quickly. How long would it take to use up your employer group lifetime benefit leaving you with no coverage besides Medicare?

What if you wanted a transplant? If you have Medicare due only to ESRD, your Medicare would end at 36 months post-transplant. [Only those with Medicare due to age or disability keep Medicare and Medicare coverage for immunos past indefinitely.] What would you tell the transplant program about your plan for paying for immunos if your Medicare and your employer group plan ended? Do you think you’d get put on the list if all you had to fall back on was pharmaceutical assistance programs? Does your state have regulations that require an insurance company to accept you when you lose Medicare? Would that company be in the standard market or would you have to get high risk insurance and pay even higher premiums to have coverage? Could you afford that?

What happens if you’re working and your employer sees premiums going up? Might your employer talk with its insurance broker about why this is happening? Would the broker look at who is overutilizing the insurance? Would the employer and broker try to figure out ways to keep premiums costs as low as possible? Would the employer make employees pay more of the premium and/or have a higher deductible or would the employer reduce benefits and possibly look at ways to eliminate employees like you that overutilize benefits? If you were on dialysis and had Medicare, how would you pay for supplemental health insurance or Part D? If you weren’t disabled and didn’t have Medicare, how would you pay for other health insurance (if you could get it) and out-of-pocket costs for healthcare?

If Medicare payments had kept up with inflation, Medicare would probably pay double what it’s paying now based on the Medicare payment amount for dialysis prior to the composite rate. In my opinion, it’s wrong to shift the burden for Medicare’s underpayment to the private sector where workers’ plans are being asked to pay more and more for longer and longer.

You say quality of care isn’t better for those who pay more of the cost of care than those with Medicare. If quality of healthcare isn’t better for people with employer group health plans, how can anyone expect those patients to be willing to pay a bigger share of the costs and to advocate for something that’s against their self-interest unless they don’t understand that advocating for extension of Medicare secondary payer IS against their self-interest.

Hi Folks

Did I miss it or can someone break down the costs?

Bob O’Brien