The most screwed-up employee perk in America
December 15, 2018 9:19 PM   Subscribe

Gawande, who has been writing and speaking on the problems of the US healthcare system for most of his adult life, has long bemoaned the field’s resistance to innovation...His ideas are about to be put to their biggest test yet. In January, three of the biggest and most powerful American companies—the tech juggernaut Amazon, banking giant JPMorgan Chase; and Warren Buffett’s Berkshire Hathaway holding company—announced they were forming a joint healthcare venture; in June, they chose Gawande to run it. (slQZ)
posted by meaty shoe puppet (44 comments total) 32 users marked this as a favorite
 
I'm not even sure what to make of my intial reaction, which is to assume the venture is doomed and to hope Gawande is not consumed in the fire. Fix healthcare, yes! Giant market economy motherfuckers, no!
posted by mwhybark at 9:29 PM on December 15, 2018 [17 favorites]


"... almost nothing is known about Gawande’s plan for his second startup ... attempts to speak to him by phone and in person were similarly forestalled... But based on Gawande’s prior work, and on recent trends in employer-sponsored healthcare, it’s not hard to imagine..."

I feel like this article is click-bait masquerading as a think piece.
posted by el io at 9:31 PM on December 15, 2018 [16 favorites]


Well, the first time something like this happened, it worked out well enough. Maybe it will even outlast its parent companies, as Kaiser has done.
posted by zabuni at 9:55 PM on December 15, 2018 [16 favorites]


Zabuni has the right idea. Want substantially-better healthcare in the US with an evidence-based approach to better outcomes, lower costs, and an overall model that fits in as an incremental replacement for a traditional healthcare plan?

It already exists, and Kaiser Permanente have been doing it for decades while everyone else have largely ignored them.

I can't say that I love every single thing about Kaiser, but it's completely astonishing that it isn't the baseline for healthcare in the US.
posted by schmod at 10:28 PM on December 15, 2018 [28 favorites]


Yes, Kaiser Permanente has this, and it was originally created by the Kaiser construction company for its employees

It is the insurance, and the hospitals, and the doctors, and the pharmacy, so you don't have an incentive for a hospital to overcharge or nickle and dime you to death, or a surgeon to do extra surgery or unnecessary tests because it is the same employer.

I recently had a major health problem that involved an ambulance, several day hospital stay in intensive care, major medical care (I don't want to get into personal details), many doctors overseeing my case, first in emergency, then afterwards in the main hospital, and lots and lots of medication.

I recovered.

I recently received my bill.
Total cost $20 (including ambulance). (Really!)
Total paperwork I had to fill out: none
Number of times I had to sign something: none

They had actually billed me the $20 twice by accident, which I didn't realize until they sent me a check for $20.

(My medicine refills do require a copay of about $10 each time).

Since Kaiser is the hospital and the insurance company, they have the incentive to reduce general healthcare costs, an incentive most hospitals do not have. Do your kids get the pneumococcal vaccine? That started as an experimental program at Kaiser hospitals (we didn't enroll our kids in it at the time because it was still in the experimental stage). They are doing other studies like this.

My one complaint about single payer healthcare is what it would do to programs like Kaiser.
posted by eye of newt at 10:59 PM on December 15, 2018 [70 favorites]


My one complaint about single payer healthcare is what it would do to programs like Kaiser.

What you just described is very much like most of my experiences in the Canadian health care system, so what single payer could do is just give everybody a program like Kaiser.
posted by Homeboy Trouble at 11:09 PM on December 15, 2018 [74 favorites]


What you just described is very much like most of my experiences in the Canadian health care system, so what single payer could do is just give everybody a program like Kaiser.
--Homeboy Trouble

Except this is the US. Lots of greedy people, I mean businessmen, would find a way to mess it up, I mean make a profit as every freedom and capitalist loving American has a right to do.
posted by eye of newt at 11:14 PM on December 15, 2018 [2 favorites]


I think Gawande’s wrong on this, but I get it. He’s been immersed in the health care debate for many years and at some point you just get frustrated that the government isn’t willing or able to do what corporations, with total control and without clashing ideologies, are able to do.

But it is true that employer-sponsored health care is an anomaly related to World War II wage freezes and we need to end it because it has led to risk segmentation which is deadly to the idea of pooled risk. Furthermore, health care costs are rising faster than inflation and companies would really prefer not to deal with the uncertain costs of funding health care instead of just paying those premiums directly to workers in the form of wages.

We need to end the tax exemption for employer-paid health premiums and get everyone in the same pool. And I think Gawande knows this.

There is a surprising amount of agreement among health policy experts about what needs to happen and we just need to ignore the politics of parties who get lots of money to keep the status quo from companies benefiting from the status quo and the other party who is trying to apply a free market ideology when there is no basis for doing so.

Medicare for all, single payer, high deductible health plans with health savings accounts— there’s data to support all of these and hardcore socialists like me would be okay with any of those choices, as long as we moved away from employer sponsored health care and put us all in the same pool. Gawande knows better than to go all in with Amazon, because that’s a population with a very different funding source and a very different disease burden than the rest of us and solving their health care problems is exactly 0% extrapolatable to any one else.

And yes, Kaiser does this much better than anyone else right now. But even Kaiser hasn’t figured out what to do with the extremely poor and the extremely sick. Those people generally lose their Kaiser coverage when they start racking up huge costs and if they kept them, they would be far less successful at managing the health of their mostly “normal” patients.
posted by Slarty Bartfast at 11:36 PM on December 15, 2018 [26 favorites]


I thought this was an especially good description of our healthcare problems (in part):
"The market—with its foundations in the World War II-era expansion of employer-sponsored insurance—has produced a system of Haves and Have-nots, where the Haves overspend on bloated healthcare delivery and generally resist structural reforms they perceive as a threat, and a few Have-nots get zero care whatsoever.

Those on the political right decry any government efforts to cover the Have-nots, but, says Feder, “what drives the cost [of healthcare] is not trying to cover the people who don’t have insurance, it’s what we pay for the people who do have coverage.” The Haves drive up spending; the Have-nots bring down key health measures. And actually, so do the Haves, because there is no incentive in the current system to provide good care; the only incentive is to provide lots of care."
posted by hopeless romantique at 11:40 PM on December 15, 2018 [5 favorites]


Re: Kaiser - Kaiser insurance through Oregon's exchange (for my husband and myself) is ~$600 per month, with a $4000 deductible. The actual cost of care within the system might be low, but unless you have employer or low-income subsidies, that's quite a barrier to entry.
posted by hopeless romantique at 1:17 AM on December 16, 2018 [6 favorites]


Healthcare costs are rising more rapidly than inflation due to artificial obstacles deposited in the way of an efficient health care system.

- We have nowhere near enough doctors, and way too many profit-motivated "specialists." This is entirely on Congress, who no-kidding funds med school slots. Yes, MD should mean you live your life as an upper-middle-class professional. Upper-middle-class professionals don't own both a private horse farm and a personal airplane, and not one of the cheap ones. This is an actual doctor I go to.

- Medicare can't negotiate drug prices, by statute, to influence Pharma pricing with economies of scale. Nor the VA.

- Insurers continually test how much the insured will put up with, in terms of co-pay and deductible. Since it's YOUR LIFE IN THE BALANCE, the insured have not been pushing back.

Medicare for All is a neat and tidy solution, and the ordinary American won't see their taxes move a jot. There will be a lot of HR goons and actuarials re-training for a new career, tho.
posted by Slap*Happy at 3:37 AM on December 16, 2018 [19 favorites]


Medicare can't negotiate drug prices, by statute, to influence Pharma pricing with economies of scale. Nor the VA.

The VA absolutely negotiates (regulates) low drug prices. All federal government departments that fund healthcare (besides Medicare) - vets, current military, native tribes, prison workers, etc - have access to pharmaceuticals through the Federal Supply Schedule at very low bulk prices, set through legislation. The VA (and a few others) are able to negotiate even lower prices on their medication beyond that.

Medicare, on the other hand, provides out-patient pharmaceuticals through Part D, which is a collection of private insurance plans. Even if Medicare could negotiate on drugs, the way it's structured now means that it would primarily be insurance companies benefiting from these savings. A $10 copay would be the same for a patient whether a drug was $30 or $500, but the insurance company would sure be happier.

Most of the Medicare For All proposals include provisions to do away with Part D, and set/negotiate drug prices. One of the biggest problems with this is that most (all?) of the proposals involve incremental reform - that is, people slowly shifting from private insurance to Medicare. As more people get access to low-cost drugs at newly negotiated prices, you can bet your ass that pharmaceutical companies will raise prices for the people still stuck on private insurance to make up the loss in revenue.
posted by hopeless romantique at 3:52 AM on December 16, 2018 [4 favorites]


I trust Gawande. Implicitly. And he's very, very competent.

Oddly, probably foolishly, I trust Warren Buffett. Also very, very competent.

Bezos I do not trust, but he is in good company. He is very, very competent.

Too Big To FailTM Chase I would with a song on my lips and joy in my heart pay big bucks to watch burn to the ground, all hands on board, exits nailed shut.

An interesting story. It will be fun to watch.
posted by dancestoblue at 3:58 AM on December 16, 2018 [15 favorites]


We have nowhere near enough doctors, and way too many profit-motivated "specialists."

I saw my doctor this week, because she has walk-in hours — she is the only GP doctor I’ve ever heard of with walk in hours, but she feels strongly that people should be able to see their doctor when they’re sick — and she kept me for 20 min to tell me about how badly the Large Institution she was associated with is fucking her and every other doctor over.

There was...a LOT there, but the overall gist seemed to be that the Large Institutions know that doctors, unless they are in certain specialties, cannot afford to make a living while accepting insurance without the support of Large Institutions, and so those Large Institutions exploit the hell out of that power dynamic. They keep introducing systems meant to “streamline” things that mostly result in doctors getting inundated with direct messages from patients, patients getting access to test results without a doctor to speak to (including like...mammograms), and a total lack of support for any of the actual people who have to deal with these systems. She said it’s because some MBA told Large Institution these systems would scale and they could fire support staff. She said she works 12 hours a day, 6-7 days a week. She said her daughter, who is in medical school, sent her an article about doctors committing suicide. She said no one wants to be a doctor anymore, and she can’t blame them.

Know what the hardest specialty to get is, or was, when I dated that one surgeon like 10 years ago? Dermatology. The best and brightest want to be dermatologists. Because then their lives don’t suck.

The profit motive has no place in healthcare.
posted by schadenfrau at 4:34 AM on December 16, 2018 [28 favorites]


Even the way we do medical training here is designed to discourage any sane person from becoming a doctor. There is no reason it has to be this punishing or this expensive. Outrageous abuse of medical students and residents is baked into the system, and the lack of sufficient spaces means that plenty of aspiring doctors who have the ability are squeezed out. For what?
posted by 1adam12 at 4:43 AM on December 16, 2018 [14 favorites]


Yeah. Healthcare tied to employment is an obvious problem. And healthcare being a highly compensated industry has its (massive) issues, but just like tertiary education, healthcare in the US at it's core need price control. That's the original sin. Any market with an flat or maybe even upward sloping demand curve can't possibly be a functioning market. It's just not doable.

That's why Kaiser works btw - they've been able to implement effective price control on their controlables by internalizing things they can. Unfortunately for them it would work even better of everything were socialized.

Lack of price control is also why we end up with such massive inequalities incare.
posted by JPD at 4:53 AM on December 16, 2018 [1 favorite]


Yes, MD should mean you live your life as an upper-middle-class professional. Upper-middle-class professionals don't own both a private horse farm and a personal airplane, and not one of the cheap ones. This is an actual doctor I go to.

Interesting that you start conceding the first point almost automatically. It isn't true in other countries. In England Doctors are pretty much just middle class.
posted by srboisvert at 5:20 AM on December 16, 2018 [12 favorites]


But even Kaiser hasn’t figured out what to do with the extremely poor and the extremely sick. Those people generally lose their Kaiser coverage when they start racking up huge costs and if they kept them, they would be far less successful at managing the health of their mostly “normal” patients.

From what I can gather, Kaiser is great until it doesn't work for you and then it becomes a morass. Mental health care seems to be particularly weak, as does care for trans people (relative to other CA plans, where there's pretty decent baseline coverage in state-regulated plans).
posted by hoyland at 5:34 AM on December 16, 2018 [4 favorites]


Average GP in the UK is like 95k GBP
Average PCP in US make 195k USD

I think on a relative basis (scaled to median income) and assuming a normalize fx rate of 1.67 or so those numbers are pretty similar.

I'd assume it's at the specialty level where not only is the comp much higher in the US, but also the quantity of specialists is much higher.

Even then there all kinds of weird things happen - for example for most specialists because of how insurance cost calculations work, it's almost always a better deal to be hospital based. Also you'd much rather be an endocrinologist in Des Moines than NYC or LA, not only is CoL lower, but comp is probably higher.
posted by JPD at 5:37 AM on December 16, 2018 [2 favorites]


The focus on physician income is common and, I suspect, deliberate misdirection. How better to avoid scrutiny of profiteering than to stand up a convenient target.

“Physician services” constitute about 20% of US healthcare costs but this includes payments to private physicians’ practices and payments to larger health care entities (hospitals, ACOs, HMOs, etc. which employ physicians) which are characterized or billed by those entities as physician services. The actual amount of that top-line number paid to physicians as wages is unclear but, given real world practice overheads and studies of this question, is probably 7-8%; let’s use 10% as a nice round approximation.

Substantial, yes, but less than hospital or drug costs - or “administration costs” (which includes profits) of private health insurance which are 15-18% (versus 6% for Medicare). If we were to drop median US physician salaries to the Euro-zone average, it would drop costs 2%. Using JPD’s numbers above, say 4% on the outside. The real money is in administrative costs, drug costs, and over-utilization.
posted by sudogeek at 5:47 AM on December 16, 2018 [45 favorites]


It's the cousin of blaming teacher salaries for education spending issues. Wierdly it's probably even more misguided here, even if a doctor making 5x-10x a teacher isn't as sympathetic. Even if obviously on an absolute basis the teacher is getting screwed in a way the doctor isn't.
posted by JPD at 5:56 AM on December 16, 2018 [11 favorites]


Has all the bubblegum and unicorns that Kaiser gives us now cancelled out Edgar Kaiser's installation of for-profit health care in the US?
posted by Brocktoon at 6:12 AM on December 16, 2018


surgeon to do extra surgery or unnecessary tests because it is the same employer.

Can we please not with this? I see this come up a lot.
posted by fluttering hellfire at 6:23 AM on December 16, 2018 [2 favorites]


There was...a LOT there, but the overall gist seemed to be that the Large Institutions know that doctors, unless they are in certain specialties, cannot afford to make a living while accepting insurance without the support of Large Institutions, and so those Large Institutions exploit the hell out of that power dynamic.

The best gynecologist I've ever had was affiliated with a major nonprofit hospital in town.

One day, she got a fracture in her foot, worked six hours limping on one foot including through lunch, in excruciating pain, because she didn't have any coverage, and then lost consciousness in her office due to a separate, unrelated long-term health issue that she had been ignoring while trying to do the most she could for her patients, while also keeping her overbosses happy.

She quit after that, and went to a fancy place in the suburbs. A friend of mine decided to keep making the 45 drive out to see her, because this doctor is just that good, and it turns out that working conditions there are actually worse.
posted by joyceanmachine at 6:26 AM on December 16, 2018 [9 favorites]


I would say health care is the US has always been for-profit. My great-uncle was a dermatologist employed by Goodyear in the 1920s and 30s. He was salaried all his career (but did have an evening private practice). Many companies had in-house doctors like Kaiser, and many still do. Goodyear, GE, and others had in-house clinics because it was profitable (in that it reduced costs of paying for outside services). His brother was an ENT surgeon in Atlanta in private practice. In his case, the “profit” was his income after overhead.

Kaiser’s health care program was based on the model of the pre-1940s German private “sickness funds” which were employer-based and included vertical integration of services and add-on insurance. His success was due to this model being introduced into rapidly growing post-war California with essentially no competitors.

As an aside, the proportion of employed physicians in the US has been steadily increasing and now constitutes >50% of US doctors. On average, employed MDs salaries are less than those in private practice. Yet, health care costs increase apace.
posted by sudogeek at 6:40 AM on December 16, 2018 [2 favorites]


I think the "employed doctors" # is skewed by the hospital economics. I.e. for the speicialists I know the math is a hospital is better compensated than private practice unless you can build a practice that doesn't take insurance.

That happens because insurance pays more for a visit/procedure in hospital than at a private practice. Which is just crazy.
posted by JPD at 6:52 AM on December 16, 2018 [1 favorite]


Know what the hardest specialty to get is, or was, when I dated that one surgeon like 10 years ago? Dermatology. The best and brightest want to be dermatologists. Because then their lives don’t suck.

posted by schadenfrau at 7:34 AM on December 16 [3 favorites +] [!]


As the old joke goes, why is dermatology the best specialty to be in? Because your patients never die, they never get better, and they never call you in the middle of the night with an emergency.
posted by McCoy Pauley at 6:57 AM on December 16, 2018 [8 favorites]


Kaiser insurance through Oregon's exchange (for my husband and myself) is ~$600 per month, with a $4000 deductible.

That's exactly what my wife and I are paying for our employer sponsored high deducatble plan for 2019. However, I can put $4000 away in the HSA to cover the out of pocket max the following year (which we will take out by February, due to type I diabetes) - that's not a luxury most people have.
posted by COD at 7:19 AM on December 16, 2018 [1 favorite]


Average GP in the UK is like 95k GBP
Average PCP in US make 195k USD


Just a small point, and anecdotal, but I know very few PCPs, myself included, that work “full time.” In most systems (Kaiser included), full time = 36 or more patient contact hours, but then you add in documentation, piles of insurance paperwork, on call responsibilities and full time really means 60+ hours of work in a week and without exception anyone I know who takes that deal is just a toxic, miserable human on a fast track to burn out and suicide.

The reason for this is that our productivity requirements (as an employee physician) are set by MBA and MHA administrators who have no intuitive understanding of the amount of unaccounted work we do. We are handed budget spreadsheets that show why we need to see 100 patients in a week and we shrug and say ok and then cut our FTE so we can occasionally see our kids.

I’ve never worked more than 0.75 FTE so the salary quoted above is actually 25% less than that. Then you factor in the $300,000 educational debt everyone is saddled with and shave another $25,000 per year off the salary. (I’ve always worked in community health where salaries are another 25% lower but my wife is the bread winner so I have that luxury).

Since I went back to school, I cut back to 0.5 FTE and just for fun have been tracking my hours spent actually working and it has been consistently 30-40 hours per week for a half time job.

I’m not arguing that doctors are suffering for lack of money, just that the system that is abusive to patients is also abusive to its employees. We unionized. Contract negotiations start next month. We’ll see if it helps. I suspect it will actually put our organization’s viability at risk but my hope is that administration starts taking seriously how fucked the situation is and instead of playing ball they push back and negotiate hard with our highly profitable payers and lobby the state legislature and advocate for the health care mission.

Also, I’m getting my MHA to become one of these bean counting goons because, although they are perfectly nice and intelligent people, none of them knows what happens on the front lines.
posted by Slarty Bartfast at 7:57 AM on December 16, 2018 [43 favorites]


This is a good explainer on our current healthcare mess and a possible move toward a capitation model and away from fee for service. Even medicaid based programs are moving this way already, my public hospital is moving toward population health, and payment based on number of patients served instead of fee for service, and that's a good thing.

And it was interesting to learn that Gawande has this extensive background in healthcare policy. I had assumed this venture appointed him purely as a famous figurehead with a high level of public trust.

But after reading this, even though there's no information about what this thing will actually be, I think we can safely say, fuck off Atul Gawande. You know that the solution is single payer, you know that Amazon and Berkshire Hathaway create low wage work and increase precarity and poor health. So fuck off. I hope you enjoy your wheelbarrows full of cash and the health security that provides.
posted by latkes at 8:03 AM on December 16, 2018 [3 favorites]


There is a surprising amount of agreement among health policy experts about what needs to happen and we just need to ignore the politics of parties who get lots of money to keep the status quo [...]

There may be agreement among health policy experts, but there's certainly no appetite among voters for getting rid of employer-sponsored health plans; at least not among voters who have a plan in place already.

Short of sodomizing a bald eagle on national TV, I can't think of a more politically suicidal platform than "raise taxes on health insurance". I mean, I'm envisioning the attack ads right now. That was part of the opposition to Obamacare, and probably where it got the most traction. (FYI, Obamacare "Cadillac tax" now delayed to... 2022. Or "two years into Somebody Else's Problem", in Washington terms.)

There's an obvious chicken-and-egg problem here, but the chances that voters are going to let Congress approach the problem by taking away existing employer-sponsored plans is absolutely zero. There needs to be a better alternative in place, for people to switch to, before you can start monkeying around with their existing plans.

"Medicare for all" is the best platform I think anyone has yet to come up with, since at least it proposes a solution. (I mean, I'm not sure it's a great one, since I think "Medicare" has a certain odor of penury attached to it, but at least it's something. "Tricare for All" or "whatever Federal employees and members of Congress get for All" would probably be better.)
posted by Kadin2048 at 10:04 AM on December 16, 2018 [5 favorites]


I personally like “the public option” if we’re choosing names. Let the states that want to create a low overhead non profit PPO and put it on the exchange and let them compete head to head with established health insurance companies. Keep the income based subsidy the same initially. If United can provide lower cost higher quality care without cherry picking the wealthiest healthiest people, I will shut up forever about the evils of capitalism in health care.

Once the state run plan is proven viable, then do away with the employer tax exemption for health care. Employers that still want to provide a health insurance benefit can still do so, but make those that choose to get out of the insurance game convert what they were paying for insurance premiums directly to wages (minus the extra tax they’ll now pay). Use the new tax revenue to liberalize the subsidy on the exchanges and employees now have more take home pay and a low cost government option for insurance, and for horrible capitalists that would never take a government plan, they still have more take home pay to give to Aetna or whoever. Employers no longer are tied to an expense that is outpacing inflation, employees are happy because they get to “see” more wages that were previously invisible to them, and if reimbursement is competitive healthcare providers would gladly contract with an entity that exists for the public good that doesn’t have Byzantine rules and dirty tricks to deny coverage and we’ve finally set up a government system that is available to everyone. Oh yeah, and you get to keep your coverage if you leave your job. Bam. Healthcare solved.
posted by Slarty Bartfast at 10:39 AM on December 16, 2018 [10 favorites]


My one complaint about single payer healthcare is what it would do to programs like Kaiser.

Kaiser is only able to cut minor costs around the edges by reducing some duplication and waste. But they are still embedded in the ridiculously expensive healthcare system of the U.S. which is twice as expensive as any other developed nation in the world.

Kaiser is still a small player with less than 4% of the healthcare market, so they have to compete with others for doctor salaries, drug prices, medical device prices and all the other stuff that makes U.S. healthcare so expensive. They are too small to force price reductions.

The only way to really force price reduction is through single-payer.
posted by JackFlash at 11:24 AM on December 16, 2018 [4 favorites]


Atul Gawande and the articles he has written for the New Yorker are my source of truth for understanding the dysfunction of the American health care system and the challenges it presents to patient/consumers. His McAllen article is almost 10 years old but still feels like it could have been written a week ago:

https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

He also penned this follow-up article more recently later that's worth checking out:

https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

This year I changed jobs and switched from Kaiser to a high-deductible HSA plan under Blue Cross Blue Shield. It's been a disaster. The biggest thing I miss with Kaiser is the organization of health care under a coherent system. The first thing I had to do with my new plan is find a primary care physician. BCBS's search feature sucks and you can't use something like Yelp because doctors and medical groups effectively SLAPP down any attempt to publicly critique them.

I ended up going with the recommendation of a friend-of-a-friend after asking around the office and talking to family and friends. I was planning to use my plan's free annual exam to evaluate this provider. I clearly stated in making the appointment with the office that I was using the free exam benefit. But because I mentioned a minor issue I had been experiencing during the exam, the office coded it as medical necessary rather than preventative. The doctor also order additional blood tests that were not covered. So I ended up being charged $500.

By the end of the exam, I had already decided I wanted nothing further to do with the doctor after he spent the whole time he was with me scribbling codes on a form then recommended 2 ultrasounds and a colonoscopy without explaining why they'd help anything.

From Gawande's 2009 article:

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

The doctor mentioned that the colonoscopy would be done there in his office.

I challenged the claim with my insurance company. You think they would be grateful that I avoided a bunch of expensive unnecessary tests. Nope. After rejecting my appeal, they said I could write a letter (like with pen and paper or maybe a word processor) appealing that decision and mail it to their offices for review. And if I wanted a second opinion, I'd be on the hook for the full cost. (I looked into it and it would be about $1000.) I haven't even seen my blood tests because they are not available online and I expect if I request them from the doctor, I'll get another bill. So the only thing I got so far for my $500 is the prospect of being harassed by bill collectors and an attack on my credit score.

By comparison, when I was with Kaiser the year before, I went in for my annual physical, mentioned a dermatological issue I was experiencing, got a preliminary prognosis, was referred to a specialist, and had it resolved within 3 weeks for well less than $100 out-of-pocket. My blood tests were available online within a couple days.

I know Kaiser or Gawande's new startup aren't cure-alls for America's medical woes. What I'm hoping is that they become practical references leading someday to a better state-managed system that functions half-way rationally.
posted by bunbury at 12:14 PM on December 16, 2018 [10 favorites]


The public option keeps the billionaire insurance company executive leeches happy but also maintains a very expensive army of admins, nurses, eligibility clerks, adjusters, etc who keep the enormous infrastructure of the insurance industry rolling. It's a massive financial extraction scheme given insurance is a totally unnecessary middle step between Healthcare providers and recipients. I think we need to talk more about the just transition of all these workers in a single (government) payer future when they (and I'm included among them as a utilization nurse) are forced to retire from this meaningless and blood sucking industry.
posted by latkes at 1:39 PM on December 16, 2018 [11 favorites]


Sometime in the late '80s, we had an office meeting where the guest speaker was a hospital administrator. She was mainly speaking about the good relationship her hospital had with my employer, but one thing she said surprised me. It was that health care was now a for-profit enterprise. I took it that she was saying that in the old days, hospitals were run as charities.
Was this the case? I know doctors always got paid, even if it was in chickens, but were most hospitals ever non-profit?
Seems this was just around the time my employer started requiring me to also contribute to my health insurance.
posted by MtDewd at 2:38 PM on December 16, 2018


Another thing that was likely left out the version of the Labyrinth myth you read in grade school: Ariadne and Theseus do not live happily ever after. On their way back to Athens, Theseus abandons Ariadne on the island of Naxos, where she dies, alone, as he sails back home.
In other versions of the story, having been left behind on Naxos, Ariadne is taken up by Dionysus, god of wine and ecstasy and all things considered probably an infinitely better boyfriend than fuckboi Theseus.

I don't really know what metaphorical implications that has for the US healthcare system, though.
posted by goblin-bee at 2:40 PM on December 16, 2018 [10 favorites]


Ariadne and Theseus do not live happily ever after

NOOOOO MY SHIP OF THESEUS


Only a little sorry.
posted by Mr. Bad Example at 3:14 PM on December 16, 2018 [11 favorites]


Those UK GP salaries aren’t particularly accurate either. About 30% of GPs are less than full time (for similar reasons to US ones, 80+ hr weeks and huge amounts of pressure).

And about a quarter of GPs are salaried (ie don’t own the practice themselves). Salaried GP pay starts at £50k and goes up to £85k (again, that’s full time).

Hospital consultants do generally work full time, and we’re paid £70-100K (most of us closer to the bottom end than the top unless you are the departmental Clinical Director or on a national committee or something). I’m not sure how that compares to the US, but it is low compared to Canada (where I work now). And having worked in both UK and Canadian systems, the work is far higher intensity in the UK, though I realise that may be location- and specialty-dependent.
posted by tinkletown at 12:58 PM on December 17, 2018


Just dropping back in to give my take on single payer.

The thought of a state sponsored public option runs aground on the shoals of GOP control of many state legislatures. They wouldn’t expand Medicaid with 100% federal support! I think that a Medicare for All proposal would likely not pass even a Dem controlled Congress, given the baseline venality and corruption in that body.

I think the best approach is the camel’s nose under the tent. Expand Medicare by allowing persons 55-65 to buy in as a public option. This still allows the insurance companies to sell the Medigap policies and will face less resistance from them given that this decile of the population is where there is an increasing prevalence of chronic illness, disability, and Medicaid use. States would prefer to unload these patients from their Medicaid programs so there is a constituency for this move.

The next steps are to gradually include in the public option for those on SS disability at qualification, then Medicaid beneficiaries and their dependents, and then opening it up to the ACA participants by offering an option in the marketplaces. Since these patients can’t afford Medigap policies at current rates, HHS can begin to offer a public option Medigap policy.

Now you have nearly 50% of the population, from children to retirees, in the system. Gradual expansion from that point can be done piecemeal by allowing, say, persons from 26-36 to enroll as they transition from their parents’ insurance, allowing those in the system to stay in the system at their choice instead of aging out of the public option, offering the public option for those who lose their insurance when their company closes or they lose their job, and so on.

How do you pay for it? Reducing return of federal tax dollars to states as states spend less to support Medicaid programs, removing the cap on earnings subject to FICA (which additionally shores up SS), subjecting AGI or capital gains to FICA instead of just wages, a ‘luxury tax’ on ‘cadillac’ health care policies, and changing the tax treatment of employee provided health plans have all been proposed and go a long way. Of course, the entire US pro-profiteer health care system needs to be changed from a fee-for-service, cost plus system to one with emphasis on preventive care, appropriate utilization, and reasonable charges. This can be enforced with a single payer. Luckily, there are many successful models out there to start from, such as Canada, UK, Japan, etc.
posted by sudogeek at 1:00 PM on December 17, 2018 [2 favorites]


My one complaint about single payer healthcare is what it would do to programs like Kaiser.

Oh, the lobbyists will take quite care of that.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 4:42 PM on December 17, 2018


I think most European healthcare systems happened as a slow transition from private to public. Ours certainly did. I was still co-paying very small amounts twenty years ago, and then it stopped.
It stopped during a conservative government, but honestly it wasn't a Nixon goes to China thing. It was more a the co-pays have gotten so small it makes no sense anymore moment.
posted by mumimor at 6:01 PM on December 17, 2018


Kaiser can exist under single payer, and could likely do especially well in a capitated single payer system (where you get paid to care for a given population, rather than fee for service) as they're already the best at keeping people healthy and skipping interventions that are not evidence based in order to save money. The single payer would just have to pay Kaiser (along with the other companies in the business of actually providing the health care).

I personally think state level single payer legislation, as is being worked on in NY and CA, should specifically be worded to require a capitated payment model. The CA legislation introduced last year was intentionally extremely vague on specifics, but I am hoping the new legislation to be introduced in 2019 gets real and that our legislators get into the real policy design that would make a system work. It's a long shot given the insurance lobby pressure and mainstream Democrat lean toward a public option (over single payer), but I have hope this can be done.
posted by latkes at 1:06 PM on December 18, 2018


latkes makes a good point; non-capitated single payer could actually turn out to be a really neat way of transferring lots of public money to private hands. They just keep turning up the costs of procedures and then use some of that money to lobby against legislative action to reduce costs, and they've got a self-sustaining money pump.
posted by Kadin2048 at 1:24 PM on December 18, 2018 [1 favorite]


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