Copied Without Permission from the WSJ

By
JEFFREY A. SINGER

Every so often I have an extraordinary and surprising experience with a patient—the kind that makes us both say, “Wow, we’ve learned something from this.” One such moment occurred recently.

A gentleman in his early 60s came in with a rather routine hernia in his lower abdomen, one that is easily repaired with a simple outpatient surgical procedure. We scheduled the surgery at a nearby hospital.

My patient is self-employed and owns a low-cost “indemnity” type of health insurance policy. It has no provider-network requirements or preferred-hospital requirements. The patient can go anywhere. The policy pays up to a fixed amount for doctor and hospital bills based upon the diagnosis. This affordable health-insurance policy made a lot of sense to this man, based on his health and financial situation.

When the man arrived at the hospital for surgery, the admitting clerk reviewed the terms of his policy and estimated the amount of his bill that would be paid by insurance. She asked him to pay his estimated portion in advance. (More hospitals are doing that now because too often patients don’t pay their portions of the bills after insurance has paid.)

The insurance policy, the clerk said, would pay up to $2,500 for the surgeon—more than enough—and up to $2,500 for the hospital’s charges for the operating room, nursing, recovery room, etc. The estimated hospital charge was $23,000. She asked him to pay roughly $20,000 upfront to cover the estimated balance. (emphasis provided)

My patient was stunned. I received a call from the admitting clerk informing me that he wanted to cancel the surgery, and explaining why. After speaking to the man alone and learning the nature of his insurance policy, I realized I was not bound by any “preferred provider” contractual arrangements and knew we had a solution.

I explained that just because he had health insurance didn’t mean he had to use it in every situation. After all, when people have a minor fender-bender, they often settle it privately rather than file an insurance claim. Because of the nature of this man’s policy, he could do the same thing for his medical procedure. However, had I been bound by a preferred-provider contract or by Medicare, I wouldn’t have been able to enlighten him.

Hospitals and other providers make their “list” prices as high as possible when negotiating contracts with health plans and Medicare regulators. No one is ever expected to pay the list price. Anybody who has seen an “Explanation of Benefits” statement from a health plan will note a very high charge from the provider, and an “adjusted charge” based upon the contracted fee schedule, which usually leaves the patient with little or nothing in out-of-pocket expenses. The only people routinely faced with list prices are those few people who have insurance like my patient’s—that doesn’t include a pre-negotiated fee schedule with contracted providers—or those who have no insurance.

Most people are unaware that if they don’t use insurance, they can negotiate upfront cash prices with hospitals and providers substantially below the “list” price. Doctors are happy to do this. We get paid promptly, without paying office staff to wade through the insurance-payment morass.

So we canceled the surgery and started the scheduling process all over again, this time classifying my patient as a “self-pay” (or uninsured) patient. I quoted him a reasonable upfront cash price, as did the anesthesiologist. We contacted a different hospital and they quoted him a reasonable upfront cash price for the outpatient surgical/nursing services. He underwent his operation the very next day, with a total bill of just a little over $3,000, including doctor and hospital fees. He ended up saving $17,000 by not using insurance. (emphasis provided)

This process taught us a few things. First, most people these days don’t have health “insurance.” They have prepaid health plans. They pay premiums to take advantage of a pre-negotiated fee schedule arranged for and administered by a third party. My patient, on the other hand, had insurance.

Second, even with the markdown for upfront “cash-pay” patients, none of the providers was losing money on my patient. Otherwise they wouldn’t have agreed to the prices. With the third-party payer taken out of the picture, we got a better idea of the market prices for the services. It is the third-party payment system that interferes with true price competition, so “market clearing prices” can’t develop.

Take the examples of Lasik eye surgery or cosmetic surgery. These services are not covered by insurance. Providers compete on the basis of quality, outcomes and price. And prices have continually dropped as quality and services have improved—unlike the rest of health care.

When my patient returned for his post-op visit we discussed the experience. It was clear to both of us that the only way to make health care more affordable is to diminish the role of third-party payers. Let consumers and providers interact through market forces to drive down prices and drive up quality, like we do when we buy groceries, clothing, cars, computers, etc. Drop the focus on prepaid health plans and return to the days of real health insurance—that covers major, unforeseen events, leaving the everyday expenses to the consumer—just like auto and homeowners’ insurance.

Sadly, we are heading in the exact opposite direction. ObamaCare expands the role of the third party and practically eliminates the role—and the say—of the patient in the delivery of health care. Will they ever learn?

Dr. Singer practices general surgery in Phoenix, Ariz., and is an adjunct scholar at the Cato Institute.

A version of this article appeared August 22, 2013, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: The Man Who Was Treated for $17,000 Less.

Free Riders

WalMart, arguably the largest employer in the United States, is frequently the target of criticism for its parsimonious pay and benefits package. And they know it. In a smoking gun type memo from 2005, they look hard at their health care benefits. While the memo is nearly a decade old, most of the observations and conclusions seem current. In particular, they know their reputation suffers:

Wal-Mart’s healthcare benefit is one of the most pressing reputation issues we face because well-funded, well-organized critics, as well as state government officials, are carefully scrutinizing Wal-Mart’s offering. Moreover, our offering is vulnerable to at least some of their criticisms, especially with regard to the affordability of coverage and Associates’ reliance on Medicaid.

They in part blame the health of their workforce. A couple of Plum Liners often note the WalMart is the employer of last resort. You work there because you can’t get a better job somewhere else.

Our workers are getting sicker than the national population, particularly with obesity-related diseases. For example, the prevalence of coronary artery disease in Wal-Mart’s population grew by 6 percent compared to a national average of 1 percent, and the prevalence of diabetes in our population grew by 10 percent compared to a national average of 3 percent. (That said, our workforce is no sicker at present in absolute terms than the national population.)

A segment of our workforce consumes healthcare inefficiently, in a pattern similar to a Medicaid population. Our population tends to over utilize emergency room and hospital services and underutilize prescriptions and doctor visits. This pattern is most evident among our low-income Associates, and one hypothesis is that this behavior may result from prior experience with Medicaid programs.

In remarkable self-awareness, they realize that healthcare is their Achilles heel in the public mind.

Healthcare is one of the most pressing reputation issues facing Wal-Mart. Survey work done last summer shows that people’s perception of our wages and benefits is a key driver of Wal-Mart’s overall reputation. Several groups are now mounting attacks against Wal-Mart focused on our healthcare offering. These increasingly well-organized and well-funded critics – especially the labor unions and related groups, such as Wal-Mart Watch – have selected healthcare as their main avenue of attack. Moreover, federal and state governments are increasingly concerned about healthcare costs, and many view Wal-Mart as part of the problem (a view due, in part, to the work of Wal-Mart’s critics). Medicaid costs are a major priority on most governors’ agendas; already a quarter of states are spending more than 25 percent of their budgets on Medicaid, and observers across the political spectrum assert that the current system – with spiraling costs, a large population of uninsured, and an increasing number of medical bankruptcies – is unsustainable (although there is little consensus on what should take its place). In this environment, we can expect efforts like those in Maryland (which is trying to mandate that companies spend a certain percentage of revenue on healthcare) and New Hampshire (which requires health services to track where Medicaid enrollees are employed) to accelerate. Proposals such as these, if successful, will bring added costs to Wal-Mart. Moreover, these battles with critics and governments are contributing to the decline of Wal-Mart’s overall reputation.

As for being free-riders, nearly half of their employees’ dependents are either on Medicaid or just going bare.

We also have a significant number of Associates and their children who receive health insurance through public-assistance programs. Five percent of our Associates are on Medicaid compared to an average for national employers of 4 percent. Twenty-seven percent of Associates’ children are on such programs, compared to a nation al average of 22 percent (Exhibit 5). In total, 46 percent of Associates’ children are either on Medicaid or are uninsured.

In their recommendations, the realize the need to make sure their position is heard. This memo was written before the word got out that individual mandates are Kenyan Socialism but it’s interesting that at one time they supported the concept.

Become more engaged in the national healthcare debate, to position Wal-Mart as a leader in healthcare in general and on access (e.g.,individual mandates…
{snip}
Public reputation risk. Healthcare enrollment will fall several percentage points due primarily to a shift to more part-time Associates, which could draw additional attacks from Wal-Mart’s critics. Also,despite the proposed efforts, the Medicaid problem will not be “solved.” A significant number of Associates and their children will still qualify for Medicaid. Because many of these programs will offer more generous health insurance than Wal-Mart provides, many Associates will still choose to enroll in Medicaid, leaving the door open for continued attacks.

For those that decry the welfare state, it seems that they easiest way to shrink it is to make sure the private sector is not part of the problem. Increases in the minimum wage and mandatory benefits increase employment costs. Possibly a lot. Labor costs are a particularly high percentage of food service and retail. But these are jobs that cannot be easily outsourced or automated.

We have a tragedy of the commons problem in that what is good for WalMart (and their customers) is not necessarily good for the nation as a whole. It’s good to know that WalMart recognizes the problems they face. It’s less reassuring that in the nearly past decade they have done little to alter the perception of them.

Open Thread Plus Bites & Pieces

I’m still catching up from last week’s news and propaganda but I did read a couple of pieces that I thought were pretty interesting.

This was from the AP Friday.

MILWAUKEE (AP) — Abortion is still legal but getting one in many states will be difficult if laws passed this year are upheld by the courts. In a march through conservative legislatures, anti-abortion Republicans passed a wave of new restrictions that would sharply limit when a woman could terminate a pregnancy and where she could go to do so.

The push brought the anti-abortion movement closer to a key milestone, in which the procedure would become largely inaccessible in the three-fifths of the country controlled by Republicans even if still technically legal under Roe vs. Wade.

But rather than continuing to roll across the GOP heartland in synch with the pro-life movement’s plan, the effort may now be hitting a wall. The obstacle comes not from opposing Democrats but from GOP leaders who believe pressing further is a mistake for a party trying to soften its harder edges after election losses last year.

The resisting Republicans include governors and top legislators in more than a half-dozen states, including some of the largest and most politically competitive in the party’s 30-state coalition. They are digging in to stop the barrage of abortion proposals, hoping to better cultivate voters not enamored with the GOP’s social agenda.

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This one’s a little long but a fascinating read on our 40 year war against marijuana.  I don’t indulge but it’s pretty clear, I think, that it’s time to change our policies.  I loved this Nixon quote.

President Nixon had already made up his mind. In May 1971 he told H.R. Haldeman, “I want a goddamn strong statement about marijuana. Can I get that out of this sonofa-bitching, uh, domestic council? I mean one on marijuana that just tears the ass out of them.” And Nixon told Shafer directly, “You’re enough of a pro to know that for you to come out with something that would run counter to what the Congress feels and what the country feels, and what we’re planning to do, would make your commission just look bad as hell.”

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I’m pretty sure this isn’t going anywhere but it’s the thing I’ve been talking about since 2009…………..jeeze.  Medicare for all.  Here’s the money quote that makes it dead on arrival.

“Paradoxically, by expanding Medicare to everyone we’d end up saving billions of dollars annually,” he said. “We’d be safeguarding Medicare’s fiscal integrity while enhancing the nation’s health for the long term.”

Friedman said the plan would be funded by maintaining current federal revenues for health care and imposing new, modest tax increases on very high income earners. It would also be funded by a small increase in payroll taxes on employers, who would no longer pay health insurance premiums, and a new, very small tax on stock and bond transactions.

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And since we have peppers coming out of our ears (garden) here I thought I’d post my Baked Jalapeno Poppers recipe.

I use a combination of whatever peppers we have in the garden.  I can usually get about 15 to 18 poppers from this recipe.

Slice peppers in half lengthwise and remove seeds and membrane.  I like to leave part of the stem on.

Combine:

8 oz cream cheese

1 1/2 cup mozarella, jack or pepper jack cheese

1/2 tsp cumin

1/2 tsp or less cayenne

Stuff peppers with cheese mixture.

Bowl one:  1/2 cup seasoned flour

Bowl two:  2 eggs

Bowl three:  1 cup seasoned bread crumbs (I use plain bread crumbs and season them myself)

Seasoning:  salt, pepper, paprika, garlic powder, onion powder, cayenne pepper and Mexican oregano to taste.  I just wing it and add to both flour and bread crumbs.

Roll peppers in flour, then dip in egg and finally dredge with bread crumbs.  Refrigerate several hours and then bake in a 350 oven for about 1/2 hour……………..yummy

In the News Now

Grand Old Party for a Brand New Generation

There was a lot of internet chatter about the above “GOP for a New Generation” report today.  Out of curiosity I decided to read it.  It was really interesting and while it doesn’t have much to do with our recent discussion of whether the Republican Party has moved right or not, I think it’s indicative of where they could use some improvement.

I happen to be the mother of young voters just outside of this under 30 age group, and because I’ve enjoyed watching their political views form so much, I thought this was a great study.

To be clear, in addition to the parts I’ve excerpted, they also polled economic matters, the size of government (interesting results there), the environment, and also discussed the use of social media and other sources of political news.

The following report assesses the findings from a variety of studies on young voters, including a new March 2013 survey conducted for the College Republican National Committee (CRNC), and makes recommendations about how Republicans can begin this work today.

We believe that Republicans can win young voters but that it will require a significantly different approach than has been used in recent elections.

Health Care

Health care remains a second-tier issue behind the economy and the national debt. In the August 2012 XG survey, only 8% of young voters said it was their top issue, and just 27% named “lowering health care costs and improving care” as one of their top two or three priorities in the March 2013 CRNC survey.

Nonetheless, the issue is at the top of the second tier in both surveys and came up frequently in our focus group research. In the August XG survey, young voters handed Democrats a heavy advantage on the issue, preferring their handling of health care to Republicans by a 63-37 margin. Some 41% thought things overall would be better as a result of Obama’s health care reform plan (versus to 32% who said things would be worse).

Many of the young people in our focus groups noted that they thought everyone in America should have access to health coverage. In the Spring 2012Harvard Institute of Politics survey of young voters, 44% said that “basic health insurance is a right for all people, and if someone has no means of paying for it, the government should provide it”; 23% disagreed.

Admittedly, there were concerns about the cost and quality of health care under the ACA but in general the young people gave Obama credit for trying.

Immigration

While immigration wasn’t a major issue it appeared it might be an issue that could turn a voter against a conservative candidate who they agreed with on taxes or other economic issues but disagreed with on immigration reform.

The position taken most frequently by young voters was that “illegal immigrants should have a path to earn citizenship,” chosen by35% of respondents. Closely behind this were the 30% who preferred the “enforcement first” strategy of securing the border and enforcing existing immigration laws. Some 19% chose “illegal immigrants should be deported or put in jail for breaking the law,” while another 17% took the position that “illegal immigrants should have a path to legal status but not citizenship.”On the issue of laws that “would allow illegal immigrants brought to the U.S. as children to gain legal resident status if they join the military or go to college,” three out of four (75.3%) young adults agreed in an October 2012 poll conducted by CIRCLE. And young voters for the most part knew how the candidates in the election stood on that issue; in that same survey, 63% of respondents said that Barack Obama was the candidate who supported “allowing many illegal or undocumented immigrants who were brought to the United States as children to remain in the country,” while only 3% said that was Mitt Romney’s position.

Abortion

This really surprised me; I knew it was pretty close but not quite this close.  In this case I wish Dems would alter their position a little to make room for a more tolerant culture of life position, but I repeat myself.

The results debunk the conventional wisdom on the issue and establish that not all “social issues” are viewed the same. Indeed, only 16% of young voters preferred that abortion be legal in all cases, while 32% said abortion should be legal “up to a certain point.” Combined, that comprises 48% who take a position leaning toward legality. On the other side, 37% felt abortion should be illegal with exceptions, and 14% thought abortion should always be illegal, making a combined 51% who lean toward prohibiting abortion. On this issue, there is small gender divide, with men in the survey actually tending to lean more pro-choice than women.

Where the Republican Party runs into trouble with young voters on the abortion issue is not necessarily in being pro-life. On the contrary, the Democratic Party’s position of pushing for abortion to be legal in all cases and at all times, including some recent laws around how to handle medical care for babies born alive during abortion procedures, is what is outside the norm of where young voters stand. Unfortunately for the GOP, the Republican Party has been painted – both by Democrats and by unhelpful voices in our own ranks – as holding the most extreme anti-abortion position (that it should be prohibited in all cases). Furthermore, the issue of protecting life has been conflated with issues around the definition of rape, funding for Planned Parenthood, and even contraception.

In the words of one pro-life respondent, “The Planned Parenthood thing for me is not so much about abortion; it’s about counseling before you can get to that point, and I feel that that’s a big part of what they do, is contraception counseling and about being safe.”

Bingo

Gay Marriage

Perhaps no topic has gotten more attention with regards to the youth vote than the issue of gay marriage. And on this issue, the conventional wisdom is right: young people are unlikely to view homosexuality as morally wrong, and they lean toward legal recognition of same-sex relationships. Only 21% of young voters in the Spring 2012 Harvard Institute of Politics survey felt that religious values should play a more important role in government, and only 25% felt homosexual relationships were wrong. Young people nowadays are more likely than ever to know someone who is openly gay or lesbian, and that factor is correlated with attitudes supporting same-sex marriage.

Surveys have consistently shown that gay marriage is not as important an issue as jobs and the economy to young voters. Yet it was unmistakable in the focus groups that gay marriage was a reason many of these young voters disliked the GOP.

The conclusion of the report discusses five areas where they think the GOP can improve their chances to win over a larger percentage of the youth vote and they explain their methodology and whatnot.

I’m still working on an immigration post, just thought this was interesting and current considering all the references I read about it today on both sides of the political divide.

Not Your Ordinary Marketplace

http://tinyurl.com/m4qjapm

Some takeaways:

Whether directly from their wallets or through insurance policies, Americans pay much more for almost every interaction with the medical system.

High prices mostly result not from top-notch patient care, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.”

Consumers, the patients, do not see prices until after a service is provided, if they see them at all.

Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending (NoVA has told us this, of course).

Even doctors often do not know the costs of the tests and procedures they prescribe.

Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.

The article focuses on colonoscopies as a case study of an ordinary procedure run amok. If the American health care system were a true market, the increased volume of colonoscopies — numbers rose 50 percent from 2003 to 2009 for those with commercial insurance — might have brought down the costs because of economies of scale and more competition. Instead, it became a new business opportunity, and moved out of the office and into the hospital.

The cost of a colonoscopy in the United States varies staggeringly, from place to place, and even within a city. Austin averages four times Baltimore, for example. New York is even higher, of course.

It is the pricing of these ordinary medical procedures that surprises me as a major contributor to our inflated health care costs.

I recommend the linked article.

Sunday Open Thread

76,000 qualified nursing school applicants were turned away in the last 12 months.

http://www.npr.org/blogs/health/2012/08/03/156213925/nursing-schools-brace-for-faculty-shortage

My advice: don’t bother with the Danish raunch comedy movie, Klown.

Seven minutes of terror:

http://www.economist.com/blogs/babbage/2012/08/landing-mars-science-laboratory

Despite speculation, the Castro twins are the future of the D Party in TX, if it has a future.  I will go further: they represent the future of the entire D Party, if it has a future.

http://www.texastribune.org/texas-politics/julian-castro/despite-speculation-castro-not-eyeing-new-role/

Just why would Iranians have a “pilgrimage” to Damascus?

http://www.washingtonpost.com/world/middle_east/syrian-rebels-say-captured-iranians-are-members-of-pro-government-militias-not-pilgrims/2012/08/05/b93a8730-df14-11e1-a19c-fcfa365396c8_story.html?hpid=z1

British jocks are performing so well in front of the home crowd.  Congrats to all the Brit medal winners.  Murray beat Federer.

What’s Next

The PPACA extends the current system to more people to increase coverage, but doesn’t fundamentally reform health care at the delivery level. As such, it will not succeed in bending the cost curve to make the growth rate of health care spending sustainable. The interesting question now is what path it takes when it inevitably collapses. I see one of two options: 
 
1. “Individual Market Based” – Some combination of Ron Wyden’s and Paul Ryan’s reforms are enacted eliminating the employer based tax preferences and replacing them with individual tax credits, thus eliminating the already tenuous “firewall” between the exchanges and the employer based system.  
 
Medicare and Medicaid (and potentially TriCare) are voucherized and integrated into the existing subsidy system in the exchanges so that all health insurance is purchased by individuals in the exchange system with varying levels of subsidies and tax credits based on age and income. About as close to “Free Market” as you are likely to get. 
 
2. “Single Payer (sort of)”. Medicaid for all is enacted replacing the exchange system entirely with a universal minimal standard insurance package provided by the government. Coverage and reimbursement is dictated by a more robust version of the Medicare Payment Advisory board that strictly limits name brand drugs and other expensive treatments in favor of generics and applies similar cost/benefit analysis to approved procedures (and reimbursement rates). The ability to see specialists without a referral or otherwise go “out of network” is curtailed, as are end of life procedures.  
 
In parallel with the public system, private insurance and medical care remain to provide enhanced care for those who can afford it.  
 
Eventually, the public system comes to resemble public schools vs private schools as taxpayers who opt for the private system are not receptive to tax increases to maintain and improve a public system that they themselves do not participate in, thus regulating the public system to a second tier level of care, much like Medicaid is today.

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