Everything Old is New Again: Some people opt to just pay their doctor
December 29, 2015 6:19 PM Subscribe
Direct Primary Care: An Alternative to Conventional Health Insurance There are roughly 4,400 direct primary care physicians nationwide, up from 756 in 2010 and a mere 146 in 2005.
This article asks physicians: Is the direct primary care model right for you? There is a coalition trying to work out the legal issues with it at the state and federal level. Here is the American Academy of Family Physicians page on this model.
According to Wikipedia:
This article asks physicians: Is the direct primary care model right for you? There is a coalition trying to work out the legal issues with it at the state and federal level. Here is the American Academy of Family Physicians page on this model.
According to Wikipedia:
Typically a direct primary care arrangement is paired with either:
A high-deductible health plan, as DPC alone will not cover catastrophic health care such as most surgeries
A health savings account, or health reimbursement account as the associated tax-benefits can generally be applied to DPC and other medical expenses.
One of the lesser known provisions of the Patient Protection and Affordable Care Act can be found in Section 1301 (and amendment Section 10104). This provision allows for direct primary care to compete with traditional health insurance options in the mandated Health insurance exchange when combined with a low cost high deductible plan.
Maybe because they're trying to distance themselves from inventing the individual mandate?
posted by scruss at 7:27 PM on December 29, 2015 [5 favorites]
posted by scruss at 7:27 PM on December 29, 2015 [5 favorites]
Can anyone elucidate what the Heritage Foundation's interest in this is?
Making their rich conservative overlords even richer, I assume.
posted by Aizkolari at 7:40 PM on December 29, 2015 [10 favorites]
Making their rich conservative overlords even richer, I assume.
posted by Aizkolari at 7:40 PM on December 29, 2015 [10 favorites]
A great deal of the "bureacracy" they refer to is not, in fact, "government" bureacracy. It's the vast private-sector, for-profit bureaucracy of insurers and HMOs.
Compare, for example, US health care spending as a percentage of GDP, with countries that have single-payer public health insurance (pdf).
posted by mandolin conspiracy at 7:49 PM on December 29, 2015 [36 favorites]
Compare, for example, US health care spending as a percentage of GDP, with countries that have single-payer public health insurance (pdf).
posted by mandolin conspiracy at 7:49 PM on December 29, 2015 [36 favorites]
So I'm currently in a family medicine residency program and I have some reservations about this model, especially regarding how it might impact access to primary care for poor folks. The American College of Physicians recently put out a policy paper on the subject (tl;dr blog version) which states,
I mean, I get it. As a junior resident I can guarantee you that I've had my fill of oppressive hospital/insurance bureaucracies and the reams of concomitant paperwork. (You haven't lived until you've argued for an hour with an insurance company pharmacist in order to get your patient the antibiotics they need.) I get how frustrating it can be to make about as much as a public school teacher working eighty-hour weeks of ten-minute clinic visits while having to service a debt the size of a McMansion. Physicians shouldn't have to accept lower reimbursement rates to take care of poorer patients, but they also shouldn't be allowed to discriminate based on socioeconomic status. They already kind of do, and the results are often tragic.
As to why Heritage is in on the action, I assume it's because they have an ideological interest in protecting hospital systems' rights to discriminate based on anticipated payout. They similarly have white papers decrying the injustice of EMTALA requiring hospitals to stop you from bleeding to death before they check to see what's in your wallet.
posted by The White Hat at 8:00 PM on December 29, 2015 [48 favorites]
Because DPCPs often limit their patient panels to several hundred patients compared with the typical 2500-plus panel size (6), there is concern that such downsizing, especially when associated with retainer fees, could create a barrier to lower-income persons, patients with chronic diseases, and other underserved populations.The paper goes on to recommend that docs think seriously about these issues before deciding to adopt this practice model. It also calls for a lot of new research that is currently lacking regarding how DPC compares with more proven models such as the Patient-Centered Medical Home. The AAFP, which currently offers docs a Direct Primary Care Toolkit for $250, is considerably more gung-ho.
One study (7) found that retainer physicians have smaller proportions of patients with diabetes than their nonretainer counterparts, and they care for fewer African-American and Hispanic patients. The study does not definitively address whether the case mix of retainer practices is causally driven by their retainer status or whether these practices tend to emerge in high-income areas where there are fewer African-American and Medicaid patients.
The literature (8, 9) has some examples of DPCPs that charge comparatively low retainer fees, and/or do not accept health insurance, and have made their practices accessible to lower-income, uninsured, and other vulnerable populations, possibly at less cost to the patient than if the practice accepted traditional insurance.
[...]Practices that downsize patient panels could potentially place an even greater strain on physicians that remain in the larger system. Yet DPCPs may lead more physicians to stay in practice, rather than close their practices altogether, which could have a beneficial effect on alleviating workforce shortages. The effect of DPCPs on projections of workforce shortages requires more study.
[...]The ethics policies of ACP, as embodied in the College's Ethics Manual, Sixth Edition (12), state that physicians have both individual and collective responsibilities to care for all. Such ethical considerations must guide physicians in considering the types of practices they choose to participate in and what they must do to ensure their practices provide accessible care to patients in a nondiscriminatory manner. Practices that, by design, exclude certain categories of patients should be understood to create a greater potential of being discriminatory against underserved populations and require special attention by physicians to the ethical considerations involved. Practices that downsize their patient panels also must be aware of ethical and legal considerations relating to patient abandonment.
I mean, I get it. As a junior resident I can guarantee you that I've had my fill of oppressive hospital/insurance bureaucracies and the reams of concomitant paperwork. (You haven't lived until you've argued for an hour with an insurance company pharmacist in order to get your patient the antibiotics they need.) I get how frustrating it can be to make about as much as a public school teacher working eighty-hour weeks of ten-minute clinic visits while having to service a debt the size of a McMansion. Physicians shouldn't have to accept lower reimbursement rates to take care of poorer patients, but they also shouldn't be allowed to discriminate based on socioeconomic status. They already kind of do, and the results are often tragic.
As to why Heritage is in on the action, I assume it's because they have an ideological interest in protecting hospital systems' rights to discriminate based on anticipated payout. They similarly have white papers decrying the injustice of EMTALA requiring hospitals to stop you from bleeding to death before they check to see what's in your wallet.
posted by The White Hat at 8:00 PM on December 29, 2015 [48 favorites]
Last decade, this was identified as 'concierge' medicine. As in, medicine for the 1%.
The emperor has new clothes, I guess.
posted by Dashy at 8:09 PM on December 29, 2015 [17 favorites]
The emperor has new clothes, I guess.
posted by Dashy at 8:09 PM on December 29, 2015 [17 favorites]
When they're trying to talk doctors out of participating in health insurance? You know what, I don't hear "stop taking Aetna or BCBS". I hear "stop taking Medicare and Medicaid", which seems to be born out by the article. Because the average Medicare/Medicaid recipient can totally afford to pay $60/mo for a health care subscription fee plus $10/visit plus "discount plan" medications. I love that the guy wants to take credit for arranging something where you literally can't help but trip over drug discount plans these days. They're better than nothing. They aren't as good as insurance, and they're definitely not as good as Medicaid.
If these people just wanted to have an alternate revenue model, they wouldn't need lobbyists. I was self-pay at my psychiatrist for years when I was in school and getting most of my primary care through the university and willing to bear the risk of not having catastrophic coverage. (There was no Medicaid at that point for people without kids, in my state.) Paying cash isn't novel. Trying to justify refusing to see low-income patients, the people most in need of better primary care, because bureaucracy? That's... special. Great, if you want to be done with bureaucracy, start giving away your services to the people who can't pay, the way my grandfather did in the days before insurance. If your model is "poor people need to pay more for access to health care", it's a bad model.
posted by Sequence at 8:09 PM on December 29, 2015 [7 favorites]
If these people just wanted to have an alternate revenue model, they wouldn't need lobbyists. I was self-pay at my psychiatrist for years when I was in school and getting most of my primary care through the university and willing to bear the risk of not having catastrophic coverage. (There was no Medicaid at that point for people without kids, in my state.) Paying cash isn't novel. Trying to justify refusing to see low-income patients, the people most in need of better primary care, because bureaucracy? That's... special. Great, if you want to be done with bureaucracy, start giving away your services to the people who can't pay, the way my grandfather did in the days before insurance. If your model is "poor people need to pay more for access to health care", it's a bad model.
posted by Sequence at 8:09 PM on December 29, 2015 [7 favorites]
We earn enough to access a basic concierge practice, but not nearly enough to forego insurance. I'd love to be able to dispense with it, because it is both frustrating and immoral to have every medical need filtered through the insurance company, but that would take a huge amount more money than I currently have.
posted by Dip Flash at 8:25 PM on December 29, 2015 [1 favorite]
posted by Dip Flash at 8:25 PM on December 29, 2015 [1 favorite]
Can anyone elucidate what the Heritage Foundation's interest in this is?
See, no one needs Obamacare when they can just pay their doctor directly. No government regulations required.
posted by T.D. Strange at 8:43 PM on December 29, 2015 [4 favorites]
See, no one needs Obamacare when they can just pay their doctor directly. No government regulations required.
posted by T.D. Strange at 8:43 PM on December 29, 2015 [4 favorites]
I'm actually kind of in favor of this, at least on a small scale. If conservatives really want to tout the free market as the greatest engine for efficiency and innovation, let's have it. See, most rednecks, because they are either uninsured or on the dole of Medicaid, Medicare, or the VA, have no idea that there's never been an actual "market" in "free market" health care. No one gets to choose meaningfully what insurance company administers their benefits, most doctors don't get to choose what plans their administration decides to contract with and people on the consumer end and producer end of the equation are completely beholden to this behemoth in the middle that takes home record profits every year, not by keeping people healthy so they consume less healthcare over their lifetime (that's difficult to do and expensive, and hey isn't that the doctor's job?) but by denying them care until the next fiscal year when it's on some other insurance company's books. And doctors employ armies of coders and billers to get their contractual pay and spend hours of their day proving to a company that knows nothing about the patient that they've been taking care of someone for a decade and slightly more expensive drug X works better because Reasons that would take All Day to Explain via hand written fax.
We've been able to provide primary care for a tiny fraction of people's out of pocket costs with insurance for a long time now. The problem is with MRIs and needing specialists and oh yeah you might need a heart transplant one day.
I left private practice because I couldn't live with myself working for such a corrupt, humiliating, and ineffective system. I went into community health where we had one payer -- the government -- and good number of uninsured patients and I will tell you it is a hell of a lot easier getting a hospital to do a free MRI for charity than it is to get an insurance company to pay for one they are actually supposed to pay for. Now, thanks to ACA (which is undoubtedly an heroically good thing for the average American) I'm back dealing with insurance companies managing the care of poor and disabled people, and trying to make a profit at it when these people will *always* cost the system inordinate amounts of money. I guess the difference is that a legislator might listen to a health care lobbyist as opposed to a doctor in the trenches.
But yeah, bring it on, because I am certain I could save more money and provide better more efficient care with the patients well being as my prime motivator that the endless, endless faxes and emails from insurance companies denying payment and asking if I'd tried Obvious Dumbass Thing #s 1-4 first even though they've already received claims for Obvious Dumbass Things 1-4 already.
Yeah I worry about increasing numbers of health care related bankruptcies in such a system, yeah I worry about access issues in this era of profound primary care shortage, but I wasn't trained as an insurance company administrator and I'll be damned if they try to make me one. So any things better than United, Humana, and Aetna calling the shots and I'll take it.
Of course Americans time and time again have said that health care is a right and they *dont* want a market based system where they question whether they really want to take their kid in just because they are vomiting blood and if this is what they want, let's give it to them in the form of a simple single payer system and putting actual health care providers and patients in charge of it. We're not idiots, we know it has to be paid for, but we also know it needs to serve the needs of the people.
posted by Slarty Bartfast at 8:51 PM on December 29, 2015 [43 favorites]
We've been able to provide primary care for a tiny fraction of people's out of pocket costs with insurance for a long time now. The problem is with MRIs and needing specialists and oh yeah you might need a heart transplant one day.
I left private practice because I couldn't live with myself working for such a corrupt, humiliating, and ineffective system. I went into community health where we had one payer -- the government -- and good number of uninsured patients and I will tell you it is a hell of a lot easier getting a hospital to do a free MRI for charity than it is to get an insurance company to pay for one they are actually supposed to pay for. Now, thanks to ACA (which is undoubtedly an heroically good thing for the average American) I'm back dealing with insurance companies managing the care of poor and disabled people, and trying to make a profit at it when these people will *always* cost the system inordinate amounts of money. I guess the difference is that a legislator might listen to a health care lobbyist as opposed to a doctor in the trenches.
But yeah, bring it on, because I am certain I could save more money and provide better more efficient care with the patients well being as my prime motivator that the endless, endless faxes and emails from insurance companies denying payment and asking if I'd tried Obvious Dumbass Thing #s 1-4 first even though they've already received claims for Obvious Dumbass Things 1-4 already.
Yeah I worry about increasing numbers of health care related bankruptcies in such a system, yeah I worry about access issues in this era of profound primary care shortage, but I wasn't trained as an insurance company administrator and I'll be damned if they try to make me one. So any things better than United, Humana, and Aetna calling the shots and I'll take it.
Of course Americans time and time again have said that health care is a right and they *dont* want a market based system where they question whether they really want to take their kid in just because they are vomiting blood and if this is what they want, let's give it to them in the form of a simple single payer system and putting actual health care providers and patients in charge of it. We're not idiots, we know it has to be paid for, but we also know it needs to serve the needs of the people.
posted by Slarty Bartfast at 8:51 PM on December 29, 2015 [43 favorites]
I got my family doctor through the private medicine clinics in Quebec. I mean yeah technically our health insurance is covered here, but in reality there just aren't enough doctors to go around so many of us are stuck with being told to just go to the ER. Which is fine if you have an actual emergency but you try going to the ER to tell them that you've felt kind of depressed lately or that you want a pap smear. So it costs me about 100$ per 20 minutes appointment, she's always RIGHT on time, it's easy to get an appointment at the last minute for emergencies, and since I'm paying for the time I never feel like I'm rushed, if my appointment takes longer than 20 minutes then I come back another time, she obeys the schedule. I actually like the whole not waiting 2 hours because the doctor is running late thing.
posted by Hazelsmrf at 9:09 PM on December 29, 2015
posted by Hazelsmrf at 9:09 PM on December 29, 2015
One thing that I absolutely LOVE about Canadian health care coverage though is that if my doctor tells me I need so and so test, that's it, I need that test. There's no insurance company to deny me, that's such bullshit. My doctor should know best what I do and don't need, not some insurance company deciding if it's profitable or not.
posted by Hazelsmrf at 9:15 PM on December 29, 2015 [11 favorites]
posted by Hazelsmrf at 9:15 PM on December 29, 2015 [11 favorites]
You know, I'm pretty tired of all these free market experiments that are just one more bandaid on a messed up American health care system. Everyone says it's oh-so complicated, it's oh-so difficult.
But you know what, every other developed country on the planet has already figured this out and provides the same or better quality care for 100% of their citizens at half or less the cost of the U.S.
Canada, the UK, Spain, France, Germany, Norway, Sweden, Finland, Denmark, Switzerland, Japan, Australia and all the rest have figured it out and the U.S continues to muddle along making excuses for its terrible system saying fixing this it just too hard.
The truth is that nobody who counts really wants to change the present system because they are making so much money from it.
posted by JackFlash at 9:19 PM on December 29, 2015 [43 favorites]
But you know what, every other developed country on the planet has already figured this out and provides the same or better quality care for 100% of their citizens at half or less the cost of the U.S.
Canada, the UK, Spain, France, Germany, Norway, Sweden, Finland, Denmark, Switzerland, Japan, Australia and all the rest have figured it out and the U.S continues to muddle along making excuses for its terrible system saying fixing this it just too hard.
The truth is that nobody who counts really wants to change the present system because they are making so much money from it.
posted by JackFlash at 9:19 PM on December 29, 2015 [43 favorites]
If I could get the money my wife's employer (or maybe more importantly, the tax deduction they get), I'd be all over this in a heartbeat.
My town, like perhaps a lot of towns, is home to a couple of very large "Medical Groups" that have in a borg like fashion sucked up all of the medical care in the vicinity.
I loathe them, their "consolidated" billing and the endless phone tree just to talk to someone useful.
On the other hand, my small practice ophthalmologist office is a joy to deal with.
A regular clientele, a single receptionist that remembers your kids name, and never a feeling of being rushed or patient #43 of the day.
Hell, they don't even take my insurance and I still visit them.
If I could pay someone to do general practice in the same fashion?
Yeah, sign me up.
posted by madajb at 9:42 PM on December 29, 2015 [1 favorite]
My town, like perhaps a lot of towns, is home to a couple of very large "Medical Groups" that have in a borg like fashion sucked up all of the medical care in the vicinity.
I loathe them, their "consolidated" billing and the endless phone tree just to talk to someone useful.
On the other hand, my small practice ophthalmologist office is a joy to deal with.
A regular clientele, a single receptionist that remembers your kids name, and never a feeling of being rushed or patient #43 of the day.
Hell, they don't even take my insurance and I still visit them.
If I could pay someone to do general practice in the same fashion?
Yeah, sign me up.
posted by madajb at 9:42 PM on December 29, 2015 [1 favorite]
I'm "impressed" (?), if that's the word, that they have come up with a more marketable name for "concierge medicine." But the system is the same: if you have significant disposable income and prioritize being able to see a primary care physician quickly and regularly, then you can pay a "membership fee" up front and get access to a primary care practice where you get more individualized attention.
An individual physician in a primary care practice needs to maintain a portfolio of about 2000 patients to stay economically viable. Maybe on average a patient sees a doctor twice a year, at $100/visit, so the doctor's gross is $400,000 before overhead, staff costs, and other expenses. Charge $1000/yr for a retainer, and you can make that same gross with 350 patients. The main advantage goes to doctors in metropolitan areas where the competition in primary care is stiff, the income is low, and the expenses are high.
I myself use a scaled-down version of this, having joined One Medical, where the fee is only $150/yr, but it allows me to find a primary care physician easily (many local doctors in my neighborhood had a waiting list before accepting new patients), and I can get a same-day appointment near me if I need it.
The thing is that these "solutions" are marketed as something we can solve actual, real problems in the health care system. But they're not. They're basically like the Uber or Seamless of medicine: solutions geared towards professionals with disposable income who want to save time and are willing to pay for it. This is like claiming that Seamless can solve all our hunger problems or that Uber is the solution to transport and transit: they're not-- they're just luxury goods being marketed as a means to make a profit from people willing to pay for a premium product.
posted by deanc at 9:43 PM on December 29, 2015 [17 favorites]
An individual physician in a primary care practice needs to maintain a portfolio of about 2000 patients to stay economically viable. Maybe on average a patient sees a doctor twice a year, at $100/visit, so the doctor's gross is $400,000 before overhead, staff costs, and other expenses. Charge $1000/yr for a retainer, and you can make that same gross with 350 patients. The main advantage goes to doctors in metropolitan areas where the competition in primary care is stiff, the income is low, and the expenses are high.
I myself use a scaled-down version of this, having joined One Medical, where the fee is only $150/yr, but it allows me to find a primary care physician easily (many local doctors in my neighborhood had a waiting list before accepting new patients), and I can get a same-day appointment near me if I need it.
The thing is that these "solutions" are marketed as something we can solve actual, real problems in the health care system. But they're not. They're basically like the Uber or Seamless of medicine: solutions geared towards professionals with disposable income who want to save time and are willing to pay for it. This is like claiming that Seamless can solve all our hunger problems or that Uber is the solution to transport and transit: they're not-- they're just luxury goods being marketed as a means to make a profit from people willing to pay for a premium product.
posted by deanc at 9:43 PM on December 29, 2015 [17 favorites]
See, no one needs Obamacare when they can just pay their doctor directly. No government regulations required.
I myself have noticed that the next phase of opposition to Obamacare is denigrating the very idea of insurance. This is starting to happen as people now realize that since everyone has insurance, (a) insurance doesn't make you special, and (b) the reality has hit home that YOUR money that you pay for YOUR insurance ends up paying for the health care of everyone else, even if they're not part of your social class or "deserving" of health care.
For most people, having to go to the doctor isn't a pleasant experience. People generally don't have the money to spend on "unexpected" visits to a doctor, and their lives are generally full of enough problems as it is without having to "take control of their health care expenses" which is what people pay an insurance company to do for them. The idea that the average person will spend $500-$1000/yr in addition to paying $100-$200 for a doctor's visit is absurd. On the other hand, the idea that a suburban professional would do this is pretty reasonable, and I supposed allows that person the belief that he is part of "the future of health care."
posted by deanc at 9:52 PM on December 29, 2015 [8 favorites]
I myself have noticed that the next phase of opposition to Obamacare is denigrating the very idea of insurance. This is starting to happen as people now realize that since everyone has insurance, (a) insurance doesn't make you special, and (b) the reality has hit home that YOUR money that you pay for YOUR insurance ends up paying for the health care of everyone else, even if they're not part of your social class or "deserving" of health care.
For most people, having to go to the doctor isn't a pleasant experience. People generally don't have the money to spend on "unexpected" visits to a doctor, and their lives are generally full of enough problems as it is without having to "take control of their health care expenses" which is what people pay an insurance company to do for them. The idea that the average person will spend $500-$1000/yr in addition to paying $100-$200 for a doctor's visit is absurd. On the other hand, the idea that a suburban professional would do this is pretty reasonable, and I supposed allows that person the belief that he is part of "the future of health care."
posted by deanc at 9:52 PM on December 29, 2015 [8 favorites]
I like my primary care doc, but he can only do so much. What I think
I'll eventually need if costs keep going up is someone who knows how to wheel me out from the ER to a plane that gets me to a surgeon in India.
posted by RobotVoodooPower at 10:59 PM on December 29, 2015 [1 favorite]
I'll eventually need if costs keep going up is someone who knows how to wheel me out from the ER to a plane that gets me to a surgeon in India.
posted by RobotVoodooPower at 10:59 PM on December 29, 2015 [1 favorite]
I've been seeing a lot of people getting a first hand experience of what most of the population deals with when it comes to healthcare. A co-worker had some fantastic insurance via their spouse's previous job. $250 deductible, ridiculously low co-pays, great prescription coverage, and low premiums. This person would rant and rave about Obamacare and how it would destroy healthcare. (No solutions of their own, mind you.) Until said spouse changed jobs. Now she doesn't really talk about Obamacare anymore. She was absolutely aghast at how much it would cost for her to get coverage through our company and stunned at how much it would cost to add her spouse. Oh and the deductible is $2000. Co-pays are a lot higher. She started ranting about this in disbelief, and I just leaned back and said "Welcome to the world most of us live in."
I saw another person who moved cross country and changed jobs. Got a plan through the exchange to tide him over until he was eligible for. He wasn't happy with the lack of providers in the plans that were available. Of course the office used this as an example of how horrible Obamacare was. I decided to stay out of it instead of pointing out that if he thought he could get a better plan at anything resembling an affordable rate for someone pushing 60, he didn't have to use the exchange.
The system is broken and that's obvious to almost anyone who can't afford "concierge" care. The problem is that those who can afford it are the ones with the money to control the lawmakers. Some people rant about single payer leading to rationing of care but we already have that. It's rationed by wealth. If you can't afford care, you're not going to get it. (Sure, you can get dragged into an ER unconscious and bleeding, but you can't get non-emergency care.) I always saw Obamacare as a gateway to single payer, because it lays the system out in a much fairer way and significantly slows the rise of health care costs, and yet the system is still broken. But the people who have the money to have a doctor at their beck and call won't let this happen without a fight.
posted by azpenguin at 11:25 PM on December 29, 2015 [12 favorites]
I saw another person who moved cross country and changed jobs. Got a plan through the exchange to tide him over until he was eligible for. He wasn't happy with the lack of providers in the plans that were available. Of course the office used this as an example of how horrible Obamacare was. I decided to stay out of it instead of pointing out that if he thought he could get a better plan at anything resembling an affordable rate for someone pushing 60, he didn't have to use the exchange.
The system is broken and that's obvious to almost anyone who can't afford "concierge" care. The problem is that those who can afford it are the ones with the money to control the lawmakers. Some people rant about single payer leading to rationing of care but we already have that. It's rationed by wealth. If you can't afford care, you're not going to get it. (Sure, you can get dragged into an ER unconscious and bleeding, but you can't get non-emergency care.) I always saw Obamacare as a gateway to single payer, because it lays the system out in a much fairer way and significantly slows the rise of health care costs, and yet the system is still broken. But the people who have the money to have a doctor at their beck and call won't let this happen without a fight.
posted by azpenguin at 11:25 PM on December 29, 2015 [12 favorites]
Right wingers are morally opposed to Bad People getting anything for free with their tax dollars, so much so they are willing to sacrifice the whole concept of insurance to spite the Wrong Sort of People.
posted by benzenedream at 12:23 AM on December 30, 2015 [10 favorites]
posted by benzenedream at 12:23 AM on December 30, 2015 [10 favorites]
This provision allows for direct primary care to compete with traditional health insurance options in the mandated Health insurance exchange when combined with a low cost high deductible plan.
There is no such thing as a "low cost high deductible" plan. That is misleading. The premiums may be low, but you're essentially taking on a larger portion of the out-of-pocket risk from the insurance company.
Whether or not this is intentional, (potentially misleading) language shapes perception. Note that the amendment to the Affordable Care Act in Section 1301(a)(3) discussing direct primary care uses the term "qualified health plan".
Simply stating that direct primary care can be combined with a high-deductible plan would read as a better presentation of the considerations surrounding health care costs.
posted by cynical pinnacle at 1:08 AM on December 30, 2015 [4 favorites]
There is no such thing as a "low cost high deductible" plan. That is misleading. The premiums may be low, but you're essentially taking on a larger portion of the out-of-pocket risk from the insurance company.
Whether or not this is intentional, (potentially misleading) language shapes perception. Note that the amendment to the Affordable Care Act in Section 1301(a)(3) discussing direct primary care uses the term "qualified health plan".
Simply stating that direct primary care can be combined with a high-deductible plan would read as a better presentation of the considerations surrounding health care costs.
posted by cynical pinnacle at 1:08 AM on December 30, 2015 [4 favorites]
This whole conversation makes me happy I no longer live in the US. Period.
posted by oheso at 2:01 AM on December 30, 2015 [2 favorites]
posted by oheso at 2:01 AM on December 30, 2015 [2 favorites]
Figuring out the intricacies and inanities of American health insurance is a time consuming kafkaesque nightmare that effectively shortens the amount of enjoyable life you get to live.
posted by srboisvert at 3:16 AM on December 30, 2015 [3 favorites]
posted by srboisvert at 3:16 AM on December 30, 2015 [3 favorites]
So much for:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
posted by marienbad at 3:40 AM on December 30, 2015 [1 favorite]
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
posted by marienbad at 3:40 AM on December 30, 2015 [1 favorite]
Primary care is one thing, but I don't understand how this would work you needed a specialist. The whole point of health insurance is to have a fallback in case of catastrophic expenses.
posted by forkisbetter at 5:20 AM on December 30, 2015 [1 favorite]
posted by forkisbetter at 5:20 AM on December 30, 2015 [1 favorite]
Primary care is one thing, but I don't understand how this would work you needed a specialist.
It doesn't work if you need a specialist. You'd still need insurance to cover costs beyond your PCP, unless you have oceans of money. What this concept is all about is doctors weeding-out anyone who is on profit-killing insurance or public assistance like Medicare and Medicaid. This isn't something that the vast numbers of middle-class customers are going to be able to afford.
A friend of my wife's had a PCP here in Indiana. The friend suffers from all sorts of maladies and is pretty much completely dependent on Medicaid for her survival. Earlier this year, she received a form letter from her PCP saying that the doctor was now requiring patients to pony-up a substantial monthly fee if they wanted to continue seeing them. It blatantly admitted this was to reduce the number of patients the doctor had to see and increase the amount of time the doctor could spend with each patient. It did not, of course, drop the other boot and add that it would also maintain income levels. Oh, and the letter blamed the ACA for "forcing" the doctor to take this action.
Since my wife's friend does not have a regular income beyond disability, she had to leave the doctor's care (after umpteen years) and start over with someone new. Fucking reprehensible.
posted by Thorzdad at 6:21 AM on December 30, 2015 [6 favorites]
It doesn't work if you need a specialist. You'd still need insurance to cover costs beyond your PCP, unless you have oceans of money. What this concept is all about is doctors weeding-out anyone who is on profit-killing insurance or public assistance like Medicare and Medicaid. This isn't something that the vast numbers of middle-class customers are going to be able to afford.
A friend of my wife's had a PCP here in Indiana. The friend suffers from all sorts of maladies and is pretty much completely dependent on Medicaid for her survival. Earlier this year, she received a form letter from her PCP saying that the doctor was now requiring patients to pony-up a substantial monthly fee if they wanted to continue seeing them. It blatantly admitted this was to reduce the number of patients the doctor had to see and increase the amount of time the doctor could spend with each patient. It did not, of course, drop the other boot and add that it would also maintain income levels. Oh, and the letter blamed the ACA for "forcing" the doctor to take this action.
Since my wife's friend does not have a regular income beyond disability, she had to leave the doctor's care (after umpteen years) and start over with someone new. Fucking reprehensible.
posted by Thorzdad at 6:21 AM on December 30, 2015 [6 favorites]
This thread was derailed almost from the get go. No one is advocating that people who sign up to concierge primary care practices go without insurance. It is actually a move to restore health insurance as an actual insurance product -- you pay a premium to hedge yourself against an unlikely event with a disastrous cost.
The concierge + catastrophic insurance model is going to be more cost effective for anyone who has to pay for their own health care (directly or through their employer paying it in lieu of salary) rather than putting it on the government.
When an "insurance" company covers all of your routine and expected costs it has to charge the bag-holder (you, your employer, the government) not only the full expected costs PLUS a large administrative overhead PLUS an bad incentive and adverse selection premium PLUS a profit margin (or for non-profits, the costs of tons of very well paid executives).
posted by MattD at 6:34 AM on December 30, 2015 [2 favorites]
The concierge + catastrophic insurance model is going to be more cost effective for anyone who has to pay for their own health care (directly or through their employer paying it in lieu of salary) rather than putting it on the government.
When an "insurance" company covers all of your routine and expected costs it has to charge the bag-holder (you, your employer, the government) not only the full expected costs PLUS a large administrative overhead PLUS an bad incentive and adverse selection premium PLUS a profit margin (or for non-profits, the costs of tons of very well paid executives).
posted by MattD at 6:34 AM on December 30, 2015 [2 favorites]
I'm "impressed" (?), if that's the word, that they have come up with a more marketable name for "concierge medicine." But the system is the same: if you have significant disposable income and prioritize being able to see a primary care physician quickly and regularly, then you can pay a "membership fee" up front and get access to a primary care practice where you get more individualized attention.
Yes, exactly. If you can pay that yearly fee, it really does bring the level of care you receive back to a mid-twentieth century level of acceptable care. Like I said above, we do this at a fairly basic level, nothing like the high-end concierge practices I have read about in NYC and LA. In exchange for the yearly fee (which obviously the practice uses to be able to keep the number of patients low, as described above), we get the ability to get same-day appointments, to have phone and email access to the doctors and nurses including on weekends, and to be able to rely on the practice spending serious time and effort helping to navigate medication and specialist claims through the insurance bureaucracy.
It's not some fantastic luxury space-age level of care, it is just a basic and conscientious level of care that everyone should be entitled to, but that I have found to be completely unattainable in the usual medical group practice where you get ten minute appointments (if you are lucky), scheduled way out ahead, and where it is impossible to get anyone on the phone. (And that is with good insurance -- the level of care most people are able to access is of course far lower.)
To me it is worth the cost, and I'm willing to make the sacrifices and savings elsewhere in our budget. I could see stretching our budget to paying full-cost for primary care visits, but there's no way at a middle class level to be able to forego insurance for specialists or for more serious issues, expensive medications, etc. A single doctor's appointment isn't going to be ruinous, but a set of tests or imaging easily could.
posted by Dip Flash at 6:39 AM on December 30, 2015 [2 favorites]
Yes, exactly. If you can pay that yearly fee, it really does bring the level of care you receive back to a mid-twentieth century level of acceptable care. Like I said above, we do this at a fairly basic level, nothing like the high-end concierge practices I have read about in NYC and LA. In exchange for the yearly fee (which obviously the practice uses to be able to keep the number of patients low, as described above), we get the ability to get same-day appointments, to have phone and email access to the doctors and nurses including on weekends, and to be able to rely on the practice spending serious time and effort helping to navigate medication and specialist claims through the insurance bureaucracy.
It's not some fantastic luxury space-age level of care, it is just a basic and conscientious level of care that everyone should be entitled to, but that I have found to be completely unattainable in the usual medical group practice where you get ten minute appointments (if you are lucky), scheduled way out ahead, and where it is impossible to get anyone on the phone. (And that is with good insurance -- the level of care most people are able to access is of course far lower.)
To me it is worth the cost, and I'm willing to make the sacrifices and savings elsewhere in our budget. I could see stretching our budget to paying full-cost for primary care visits, but there's no way at a middle class level to be able to forego insurance for specialists or for more serious issues, expensive medications, etc. A single doctor's appointment isn't going to be ruinous, but a set of tests or imaging easily could.
posted by Dip Flash at 6:39 AM on December 30, 2015 [2 favorites]
I've long wondered if getting insurance out of the day to day routine medical care business wouldn't be a huge step in the right direction. I'm flabbergasted every time I get routine blood tests done and see the retail cost of the blood tests at $300, insurance pays $9 (I'm not exaggerating here at all) and I pay nothing. Clearly the testing company is making money with $9 blood tests (or are making money overall using a basic test as a loss leader) but if that is the case why not just charge everybody $9? Why would it have cost me $300 had I not been insured?
(Yes, I realize that in the real world I would call and whine and get that $300 dropped to $150 pretty quickly, but still...)
So my grand idea to fix health care, coming from somebody in the software world.
1. Eliminate the insurance companies
2. Everybody has a national deductible - say 5% of your AGI, or something like that. (With allowances for low incomes, etc. so that it is not overly regressive)
3. Taxpayers collectively pay for everything above that.
If the data says that covering an annual checkup, mammograms, prostate cancer screenings, tests, etc. saves lives and money, then those types of things can be rolled into the plan too.
The basic idea that we all pay out of pocket for routine day stuff like a normal sick call. I suspect a large percentage of people in a given year wouldn't meet their deductible. I wouldn't most years. So in a sense, we run healthcare insurance like life or auto insurance, with the majority of people paying normal expenses and not filing a claim that year subsidizing those that do need their insurance.
Maybe the healthcare numbers are so extreme that this can't work financially. But as mentioned in several posts above, I suspect the real reason we haven't even looked seriously at something like this is that all those people in the middle are making way too much on the current system.
Cost control would achieved by the combination of an actual market economy in basic healthcare, since we are all paying out of pocket up front to the deductible we'll have an incentive to care, plus standard costs for procedures similar to how Medicare does it now.
posted by COD at 6:54 AM on December 30, 2015
(Yes, I realize that in the real world I would call and whine and get that $300 dropped to $150 pretty quickly, but still...)
So my grand idea to fix health care, coming from somebody in the software world.
1. Eliminate the insurance companies
2. Everybody has a national deductible - say 5% of your AGI, or something like that. (With allowances for low incomes, etc. so that it is not overly regressive)
3. Taxpayers collectively pay for everything above that.
If the data says that covering an annual checkup, mammograms, prostate cancer screenings, tests, etc. saves lives and money, then those types of things can be rolled into the plan too.
The basic idea that we all pay out of pocket for routine day stuff like a normal sick call. I suspect a large percentage of people in a given year wouldn't meet their deductible. I wouldn't most years. So in a sense, we run healthcare insurance like life or auto insurance, with the majority of people paying normal expenses and not filing a claim that year subsidizing those that do need their insurance.
Maybe the healthcare numbers are so extreme that this can't work financially. But as mentioned in several posts above, I suspect the real reason we haven't even looked seriously at something like this is that all those people in the middle are making way too much on the current system.
Cost control would achieved by the combination of an actual market economy in basic healthcare, since we are all paying out of pocket up front to the deductible we'll have an incentive to care, plus standard costs for procedures similar to how Medicare does it now.
posted by COD at 6:54 AM on December 30, 2015
This thread was derailed almost from the get go.
No.
It's not a derail to talk about
- how broken the US medical industry is
- how concierge medicine, as it exists in the US healthcare industry, is for wealthy people only
- how the US medical industry is not a "market" in any sense
- why we might want a medical industry that cares for everyone, not just the wealthy
posted by yesster at 6:54 AM on December 30, 2015 [10 favorites]
No.
It's not a derail to talk about
- how broken the US medical industry is
- how concierge medicine, as it exists in the US healthcare industry, is for wealthy people only
- how the US medical industry is not a "market" in any sense
- why we might want a medical industry that cares for everyone, not just the wealthy
posted by yesster at 6:54 AM on December 30, 2015 [10 favorites]
I don't know, I'd be more in favor of single payer if I didn't personally know people in the UK who wait for months and months to get in to see doctors if it's not a dire emergency. Trans care is especially grim, the waiting list is about a year for transgender care in London and not much better elsewhere. Wonder how many suicides that causes.
posted by desjardins at 7:06 AM on December 30, 2015 [1 favorite]
posted by desjardins at 7:06 AM on December 30, 2015 [1 favorite]
(Here's my source for the UK waiting times info. The longest, Newcastle, is 89 weeks for your first appointment! PDF)
posted by desjardins at 7:08 AM on December 30, 2015 [1 favorite]
posted by desjardins at 7:08 AM on December 30, 2015 [1 favorite]
I don't know, I'd be more in favor of single payer if I didn't personally know people in the UK who wait for months and months to get in to see doctors if it's not a dire emergency.
The ghost of Thatcher, taking the corporeal form of David Cameron? Hacking away at the funding a single-payer system receives will tend to have that effect.
This Institute for Fiscal Studies report, funded by the Nuffield Trust, examines what can be expected once the current unprecedented period of broadly flat NHS funding in real terms ends in 2014-15.
[...]
In summary, the report concludes that public funding for health is set to be tight until at least the end of the decade. As spending cuts continue in real terms through to 2016-17 and beyond, they calculate that only a long-term freeze in other public service budgets or large tax rises could enable a return to the 4.0 per cent average annual growth to which the NHS has become accustomed.
posted by mandolin conspiracy at 7:27 AM on December 30, 2015 [1 favorite]
The ghost of Thatcher, taking the corporeal form of David Cameron? Hacking away at the funding a single-payer system receives will tend to have that effect.
This Institute for Fiscal Studies report, funded by the Nuffield Trust, examines what can be expected once the current unprecedented period of broadly flat NHS funding in real terms ends in 2014-15.
[...]
In summary, the report concludes that public funding for health is set to be tight until at least the end of the decade. As spending cuts continue in real terms through to 2016-17 and beyond, they calculate that only a long-term freeze in other public service budgets or large tax rises could enable a return to the 4.0 per cent average annual growth to which the NHS has become accustomed.
posted by mandolin conspiracy at 7:27 AM on December 30, 2015 [1 favorite]
When an "insurance" company covers all of your routine and expected costs it has to charge the bag-holder (you, your employer, the government) not only the full expected costs PLUS a large administrative overhead PLUS an bad incentive and adverse selection premium PLUS a profit margin (or for non-profits, the costs of tons of very well paid executives).
This is completely true with the minor exception of every other advanced industrial democracy on Earth.
posted by ROU_Xenophobe at 7:46 AM on December 30, 2015 [7 favorites]
This is completely true with the minor exception of every other advanced industrial democracy on Earth.
posted by ROU_Xenophobe at 7:46 AM on December 30, 2015 [7 favorites]
I don't know, I'd be more in favor of single payer if I didn't personally know people in the UK who wait for months and months to get in to see doctors if it's not a dire emergency.
The UK healthcare system is run on a shoestring (our government spends less per capita than the US government). And I'd have more sympathy for your criticism if I didn't personally know people in the US who simply do not go to see their doctors if it's not a dire emergency even post Obamacare. And if on the rare occasions when the US system tracks waiting times they don't come out as comparable to the UK and frequently worse
The treatment of trans* patients is terrible (the Newcastle having a 300 patient waiting list and only seeing one new patient in six months is an absolute disgrace). But let's not pretend that that's normal. Or that the situation in the US isn't even grimmer. In 2013-14 in the Charing Cross Clinic alone under the NHS 180 cases of gender reassignment were carried out (which is half what is needed). Sounds grim? In the entire US the best estimate I'm aware of says between 800 and 1000 cases are carried out per year. In a country five times the size of the UK and where I've only counted one public sector clinic (patients in the UK can go private).
Even in the rare cases where the NHS is a disgrace US healthcare manages to somehow be worse.
posted by Francis at 8:09 AM on December 30, 2015 [16 favorites]
The UK healthcare system is run on a shoestring (our government spends less per capita than the US government). And I'd have more sympathy for your criticism if I didn't personally know people in the US who simply do not go to see their doctors if it's not a dire emergency even post Obamacare. And if on the rare occasions when the US system tracks waiting times they don't come out as comparable to the UK and frequently worse
The treatment of trans* patients is terrible (the Newcastle having a 300 patient waiting list and only seeing one new patient in six months is an absolute disgrace). But let's not pretend that that's normal. Or that the situation in the US isn't even grimmer. In 2013-14 in the Charing Cross Clinic alone under the NHS 180 cases of gender reassignment were carried out (which is half what is needed). Sounds grim? In the entire US the best estimate I'm aware of says between 800 and 1000 cases are carried out per year. In a country five times the size of the UK and where I've only counted one public sector clinic (patients in the UK can go private).
Even in the rare cases where the NHS is a disgrace US healthcare manages to somehow be worse.
posted by Francis at 8:09 AM on December 30, 2015 [16 favorites]
They can call it whatever doubleplusgoodspeak they like, "concierge care," "direct physician care," or "taking charge of your own health care." What it effectively is, once filtered through the translator, is "Go fuck off and die and save us the effort."
posted by blucevalo at 8:26 AM on December 30, 2015 [3 favorites]
posted by blucevalo at 8:26 AM on December 30, 2015 [3 favorites]
I can tell that there are a lot of (temporarily) healthy people here. Temporarily healthy people assume that the catastrophe that might befall them would be a one time acute thing, like a car accident or appendicitis. Something where you get treated, paid for by your high-deductible insurance, and then you get better and go back to being healthy and seeing your concierge doctor again. Maybe you imagine you might have a heart attack or get cancer, but even those you think of one time things that your insurance would pay for and then you would get better, when the reality is that even if you fully recover, you would most likely require ongoing monitoring by a specialist.
My reality, and the reality of many human beings, is one of chronic illness. I do see my primary care doc once a year for a check-up. But I also see a rheumatologist 3-6 times a year for monitoring and maintenance. I have blood tests for inflammation markers and organ function twice a year. I have annual x-rays to monitor joint damage. I take a weekly biologic medicine that (without insurance and a copay subsidy from the manufacturer) would literally cost $56,000 per year. I have had several rounds of physical therapy.
I am not a weirdo leaching off of the system. I am one of you, and because of all this health care I am able to work full time and pay into the system just like you do, luckily with an employer who doesn't limit me to high deductible plans.
You are currently able-bodied, but you will not stay that way. If you are lucky enough to make it through the middle of your life without cancer, an auto-immune disease, an endocrine issue, or some other chronic disease, then you will still get old. And when you do, you will have health problems. A good health care system should be designed to care for all of us through all parts of our lives.
Assume that you are about to have a baby, and you don't know if that kid is going to be born with a serious medical condition, or born healthy and grow up to be healthy like you (temporarily) are or chronically ill like me. Assume that you don't know for sure that you will be around throughout your child's life to bail them out financially from medical debts. What health care system would you want for your kid?
posted by hydropsyche at 8:27 AM on December 30, 2015 [28 favorites]
My reality, and the reality of many human beings, is one of chronic illness. I do see my primary care doc once a year for a check-up. But I also see a rheumatologist 3-6 times a year for monitoring and maintenance. I have blood tests for inflammation markers and organ function twice a year. I have annual x-rays to monitor joint damage. I take a weekly biologic medicine that (without insurance and a copay subsidy from the manufacturer) would literally cost $56,000 per year. I have had several rounds of physical therapy.
I am not a weirdo leaching off of the system. I am one of you, and because of all this health care I am able to work full time and pay into the system just like you do, luckily with an employer who doesn't limit me to high deductible plans.
You are currently able-bodied, but you will not stay that way. If you are lucky enough to make it through the middle of your life without cancer, an auto-immune disease, an endocrine issue, or some other chronic disease, then you will still get old. And when you do, you will have health problems. A good health care system should be designed to care for all of us through all parts of our lives.
Assume that you are about to have a baby, and you don't know if that kid is going to be born with a serious medical condition, or born healthy and grow up to be healthy like you (temporarily) are or chronically ill like me. Assume that you don't know for sure that you will be around throughout your child's life to bail them out financially from medical debts. What health care system would you want for your kid?
posted by hydropsyche at 8:27 AM on December 30, 2015 [28 favorites]
As to why Heritage is in on the action, I assume it's because they have an ideological interest in protecting hospital systems' rights to discriminate based on anticipated payout.
This is the same strategy the for-profit health care providers promote in Canada. "Oh well, the system forces wait times on everyone, and that's not fair to our wealthy sponsors! And let's not forget about SOCIALISM." Therefore we need a Two-Tier health care system so that those with money can get faster, better service. I've been told that several large American managed care companies set up shop decades ago in Canada, in anticipation of the time when Two-Tier becomes a reality. That this arrangement is specifically not allowed by the Canada Health Act hasn't stopped various trials and fiddling around the edges, and eventually they'll get what they want unless governments push back.
posted by sneebler at 8:50 AM on December 30, 2015 [3 favorites]
This is the same strategy the for-profit health care providers promote in Canada. "Oh well, the system forces wait times on everyone, and that's not fair to our wealthy sponsors! And let's not forget about SOCIALISM." Therefore we need a Two-Tier health care system so that those with money can get faster, better service. I've been told that several large American managed care companies set up shop decades ago in Canada, in anticipation of the time when Two-Tier becomes a reality. That this arrangement is specifically not allowed by the Canada Health Act hasn't stopped various trials and fiddling around the edges, and eventually they'll get what they want unless governments push back.
posted by sneebler at 8:50 AM on December 30, 2015 [3 favorites]
I don't know, I'd be more in favor of single payer if I didn't personally know people in the UK who wait for months and months to get in to see doctors if it's not a dire emergency.
Isn't the Conservative party in the UK actively working to starve/dismantle the NHS and privatize healthcare in the UK along the US profit centric model? Why not look at a country that spends adequately on its single payer system like France or Germany?
posted by T.D. Strange at 8:54 AM on December 30, 2015 [4 favorites]
Isn't the Conservative party in the UK actively working to starve/dismantle the NHS and privatize healthcare in the UK along the US profit centric model? Why not look at a country that spends adequately on its single payer system like France or Germany?
posted by T.D. Strange at 8:54 AM on December 30, 2015 [4 favorites]
I'm flabbergasted every time I get routine blood tests done and see the retail cost of the blood tests at $300, insurance pays $9 (I'm not exaggerating here at all) and I pay nothing.
The most recent blood test anyone in our house got was over $1000 "adjusted" down to $20 and then we wound up paying more than insurance. It's madness.
posted by Bulgaroktonos at 9:04 AM on December 30, 2015 [2 favorites]
The most recent blood test anyone in our house got was over $1000 "adjusted" down to $20 and then we wound up paying more than insurance. It's madness.
posted by Bulgaroktonos at 9:04 AM on December 30, 2015 [2 favorites]
Something where you get treated, paid for by your high-deductible insurance, and then you get better and go back to being healthy and seeing your concierge doctor again. ... My reality, and the reality of many human beings, is one of chronic illness.
I completely agree, but will add that the basic concierge service has been amazing for helping to navigate exactly the kind of chronic illness you describe. The two key things have been help with coordinating and selecting specialists, and most of all in dealing with infuriating insurance issues around medications. Having that buffer between us and the insurance company whenever there is a maddening and random "Oh, by the way, we just decided to randomly cancel coverage of the effective pain control medication that has no side effects" has been worth far more than the cost.
I think of the proposals to treat health care access along the catastrophic-only model as libertarian in the worst sense of that word, all "I've got mine so fuck you" to anyone dealing with chronic illness (or any other complex health situation, including trans issues as mentioned above). Good health care access involves having continuity of care and the support to tackle complex and life-long conditions, not just quick fixes for immediate problems.
posted by Dip Flash at 9:15 AM on December 30, 2015 [1 favorite]
I completely agree, but will add that the basic concierge service has been amazing for helping to navigate exactly the kind of chronic illness you describe. The two key things have been help with coordinating and selecting specialists, and most of all in dealing with infuriating insurance issues around medications. Having that buffer between us and the insurance company whenever there is a maddening and random "Oh, by the way, we just decided to randomly cancel coverage of the effective pain control medication that has no side effects" has been worth far more than the cost.
I think of the proposals to treat health care access along the catastrophic-only model as libertarian in the worst sense of that word, all "I've got mine so fuck you" to anyone dealing with chronic illness (or any other complex health situation, including trans issues as mentioned above). Good health care access involves having continuity of care and the support to tackle complex and life-long conditions, not just quick fixes for immediate problems.
posted by Dip Flash at 9:15 AM on December 30, 2015 [1 favorite]
The basic idea that we all pay out of pocket for routine day stuff like a normal sick call.
That assumes that you can pay out of pocket for a doctor visit. There have been times in the past that I went to the ER because I couldn't even afford my $30 co-pay. Yeah the ER cost more in the long run but when you have 2 people living on $400 per 2 weeks (that was net of bills like electricity, rent, etc.) we barely had enough to eat and pay for gas to work. Even now that I am in a much better position, it would be a serious strain if I got the flu and had to pay out of pocket to go to the doctor at $150-250 per visit.
Single payer really is the only answer that is fair to everyone.
posted by LizBoBiz at 10:22 AM on December 30, 2015 [5 favorites]
That assumes that you can pay out of pocket for a doctor visit. There have been times in the past that I went to the ER because I couldn't even afford my $30 co-pay. Yeah the ER cost more in the long run but when you have 2 people living on $400 per 2 weeks (that was net of bills like electricity, rent, etc.) we barely had enough to eat and pay for gas to work. Even now that I am in a much better position, it would be a serious strain if I got the flu and had to pay out of pocket to go to the doctor at $150-250 per visit.
Single payer really is the only answer that is fair to everyone.
posted by LizBoBiz at 10:22 AM on December 30, 2015 [5 favorites]
That's the main problem, American healthcare was never intended to be fair to everyone. It is actually functioning mostly as intended, to maximize health and insurance industry profits, with a veneer of compassion to keep up appearances (although even that may come into question at least in Red states if Heritage is driving the conversation). It's barely even a "health system" at all rather than just a sector of the economy that happens to extract wealth from the population of sick people rather than say an oil field. An actual system designed for fairness and equal access for all is completely opposed to the current health sector. The entrenched interests have every incentive to delay reform as long as possible, and to distort the political environment such that any "reform" is mostly just a market-based shuffling of deck chairs like Obamacare, maintaining their influence. A true national healthcare system or national single payer Medicare-for-all insurance system would undermine profits, which is why it will never happen as long as the people who profit from the status quo also own enough politicians to prevent it.
posted by T.D. Strange at 10:42 AM on December 30, 2015 [3 favorites]
posted by T.D. Strange at 10:42 AM on December 30, 2015 [3 favorites]
The basic idea that we all pay out of pocket for routine day stuff like a normal sick call.
And yet this "concierge" proposal is exactly the opposite. It is a one-price all-you-can-eat buffet for the wealthy. You get to see your doctor anytime you want, as many times as you want, for no extra cost.
It is not surprising to see conservatives make a proposal like this that is the direct contradiction of their repeated statements that health insurance fails because people "don't have skin in the game." Conservatives are always spouting conflicting policies with complete lack of self-awareness. In truth, they just want everyone else to have skin in the game. For themselves they want gold-plated service.
posted by JackFlash at 10:53 AM on December 30, 2015
And yet this "concierge" proposal is exactly the opposite. It is a one-price all-you-can-eat buffet for the wealthy. You get to see your doctor anytime you want, as many times as you want, for no extra cost.
It is not surprising to see conservatives make a proposal like this that is the direct contradiction of their repeated statements that health insurance fails because people "don't have skin in the game." Conservatives are always spouting conflicting policies with complete lack of self-awareness. In truth, they just want everyone else to have skin in the game. For themselves they want gold-plated service.
posted by JackFlash at 10:53 AM on December 30, 2015
I've seen this work in primary care, pre Obamacare. It does, pretty much. First off, I wouldn't categorize it as "medical care for the 1%". It could be, of course, and in some segments of the industry, such as cosmetic surgery in Beverly Hills, it is. But for the most part, it was more like "medical care for self employed" or "medical care for people who have a difficult time paying for decent insurance". This model does break down when specialists are needed in any significant extent.
It was more popular with small practices. Say, husband/wife practices. This kind of business model is a dying one, at least here in the big city. But the attraction here was obvious from a business standpoint.
Which goes on to the next point, being Heritage is flailing here. Sure, it's a strategy against big bureaucracies, but those were from big business concerns like hospitals/practice groups and insurance companies, not government so much.
One area where this model I thought was quite compelling was in what is often called the urgent care business. This was a cash pay model, in the case I was familiar with, a flat fee, utilized by lots of people for those simple things that were difficult to schedule an appointment for. It was primary care for lots of folks, and just more convenient for plenty with insurance. People come in for things that seemed like maybe overkill for a full blown doctor visit, or not quite an emergency for an ER, on a walk in basis, with generally quite reasonable wait times. This was a neat small business model that, interestingly, some bigger entities seem to bugger up.
posted by 2N2222 at 11:07 AM on December 30, 2015 [1 favorite]
It was more popular with small practices. Say, husband/wife practices. This kind of business model is a dying one, at least here in the big city. But the attraction here was obvious from a business standpoint.
Which goes on to the next point, being Heritage is flailing here. Sure, it's a strategy against big bureaucracies, but those were from big business concerns like hospitals/practice groups and insurance companies, not government so much.
One area where this model I thought was quite compelling was in what is often called the urgent care business. This was a cash pay model, in the case I was familiar with, a flat fee, utilized by lots of people for those simple things that were difficult to schedule an appointment for. It was primary care for lots of folks, and just more convenient for plenty with insurance. People come in for things that seemed like maybe overkill for a full blown doctor visit, or not quite an emergency for an ER, on a walk in basis, with generally quite reasonable wait times. This was a neat small business model that, interestingly, some bigger entities seem to bugger up.
posted by 2N2222 at 11:07 AM on December 30, 2015 [1 favorite]
When an "insurance" company covers all of your routine and expected costs it has to charge the bag-holder (you, your employer, the government) not only the full expected costs PLUS a large administrative overhead PLUS an bad incentive and adverse selection premium PLUS a profit margin (or for non-profits, the costs of tons of very well paid executives).
You are completely and totally wrong, and the fact that no other modcern country in the world thinks this way should give you a second thought, rather than assuming that you and a few fringe conservatives at think tanks are so brilliant that they have figured out health care better than the rest of the world's policy makers of modern civilization.
Here's the thing: I don't want to "take control of my health expenses" because I actually don't know what is the best/most cost effective way of making a decision between whether to spend money on preventative care now or deal with the issue later when/if it becomes more serious. (even more so, under your system, I would PAY MORE to seek preventative care and PAY LESS by waiting for it to become catastrophic, when insurance would kick in, even assuming I was able to predict correctly). I would actually prefer to work at what is, you know, my actual job that I have spent decades building expertise in, which is not health care.
Who DOES know how to make these judgments? Actuaries and health care experts. What putting these decisions in the hands of consumers does is outsource the "bad decision making" to people like me, who are computer scientists, salespeople, and other cubicle workers who have no background in health care and no market leverage to negotiate better deals with providers, so that WE pay more money, while the insurance companies save money by not having to pay for these things. In the best case scenario for an insurance company, I don't see a doctor because I don't want to pay the "up front" expense, and then I die quickly, so the insurance company doesn't have to pay for any of my care, particularly that which would have been detected in a preventative visit.
posted by deanc at 11:21 AM on December 30, 2015 [9 favorites]
You are completely and totally wrong, and the fact that no other modcern country in the world thinks this way should give you a second thought, rather than assuming that you and a few fringe conservatives at think tanks are so brilliant that they have figured out health care better than the rest of the world's policy makers of modern civilization.
Here's the thing: I don't want to "take control of my health expenses" because I actually don't know what is the best/most cost effective way of making a decision between whether to spend money on preventative care now or deal with the issue later when/if it becomes more serious. (even more so, under your system, I would PAY MORE to seek preventative care and PAY LESS by waiting for it to become catastrophic, when insurance would kick in, even assuming I was able to predict correctly). I would actually prefer to work at what is, you know, my actual job that I have spent decades building expertise in, which is not health care.
Who DOES know how to make these judgments? Actuaries and health care experts. What putting these decisions in the hands of consumers does is outsource the "bad decision making" to people like me, who are computer scientists, salespeople, and other cubicle workers who have no background in health care and no market leverage to negotiate better deals with providers, so that WE pay more money, while the insurance companies save money by not having to pay for these things. In the best case scenario for an insurance company, I don't see a doctor because I don't want to pay the "up front" expense, and then I die quickly, so the insurance company doesn't have to pay for any of my care, particularly that which would have been detected in a preventative visit.
posted by deanc at 11:21 AM on December 30, 2015 [9 favorites]
I don't know, I'd be more in favor of single payer if I didn't personally know people in the UK who wait for months and months to get in to see doctors if it's not a dire emergency.
Who are these people? During my seven years in the UK I never had to wait more than a few days and on several occasions even got to see a doctor simply by walking into the nearest clinic.
People getting surgeries or advanced specialists treatments have to wait but that is true everywhere.
posted by srboisvert at 11:39 AM on December 30, 2015 [1 favorite]
Who are these people? During my seven years in the UK I never had to wait more than a few days and on several occasions even got to see a doctor simply by walking into the nearest clinic.
People getting surgeries or advanced specialists treatments have to wait but that is true everywhere.
posted by srboisvert at 11:39 AM on December 30, 2015 [1 favorite]
I'd be more in favor of single payer if I didn't personally know people in the UK...
The UK is not a "single payer" system-- it's a single provider system, in the same way your police and fire departments are-- all health care providers in the public system work directly for the state. Canada, on the other hand, is single payer-- there is a single province-wide insurance company that pays for your care from doctors who may be working for themselves, a hospital, or a group.
Most modern countries have a hybrid public/private system, which the USA is finally moving towards.
posted by deanc at 11:45 AM on December 30, 2015 [4 favorites]
The UK is not a "single payer" system-- it's a single provider system, in the same way your police and fire departments are-- all health care providers in the public system work directly for the state. Canada, on the other hand, is single payer-- there is a single province-wide insurance company that pays for your care from doctors who may be working for themselves, a hospital, or a group.
Most modern countries have a hybrid public/private system, which the USA is finally moving towards.
posted by deanc at 11:45 AM on December 30, 2015 [4 favorites]
Anyone interested in the Canadian system might want to have listen to White Coat Black Art. It's hosted by an ER doctor who looks at health care, health care policy, and often focuses on failures or burning issues in the Canadian system. Ours is far from perfect.
There are horror stories and praise for this system, depending on who you talk to.
The one thing it does well, though, is protect people from a.) being denied emergency room care owing to insurance status and b.) from a medical emergency and hospital stay (in and of itself) resulting in a personal financial crisis.
posted by mandolin conspiracy at 1:41 PM on December 30, 2015 [4 favorites]
There are horror stories and praise for this system, depending on who you talk to.
The one thing it does well, though, is protect people from a.) being denied emergency room care owing to insurance status and b.) from a medical emergency and hospital stay (in and of itself) resulting in a personal financial crisis.
posted by mandolin conspiracy at 1:41 PM on December 30, 2015 [4 favorites]
Concierge medicine vs. direct primary care
They have some things in common, but there are differences. A chief difference is that Direct Primary Care typically costs less. It is designed to be affordable.
posted by Michele in California at 11:26 AM on December 31, 2015 [1 favorite]
They have some things in common, but there are differences. A chief difference is that Direct Primary Care typically costs less. It is designed to be affordable.
posted by Michele in California at 11:26 AM on December 31, 2015 [1 favorite]
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