The Glade 4.0

So somebody asked a while back how I'd reform the US healthcare system. I've been thinking a long time about my answer. I'm bored, so I'm typing up as much as I have time for today. This list of reforms should be taken as completely NOT inclusive.

Also, I'd like to politely request at the outset that people address original points and not go off into either "Gub'mint is bad" land or "Corporations are evil" land. The reforms I'm mentioning are designed to exist within a realistic land of "plausibly could both pass muster and function properly," not the imaginary land of how I, or you, or DailyKos, or the Teaparty wants things to be.

That said:

1) Replace the current method of paying physicians under Medicare B and Medicaid to be one that doesn't reflect RVU's and thus put pressure solely on productivity. Create some method of paying similar to DRG's that focuses on the disease or disease-process, rather than the volume of patients.

2) Remove restrictions on interstate insurance purchases.

3) Being to raise the Medicare Enrollment age over time to be slightly less than the average life expectancy. Index the enrollment age to life expectancy.

4) Gradiate Medicaid eligibility.

5) Extend protections of HIPAA regarding "pre-existing conditions" to individual plans as well as group plans.

6) Remove the tax exemption on employer-provided benefits.

7) Pass "tort reform."

8) Remove the anti-trust exemption for health insurance companies.

9) Phase-in (possibly over as much as a decade) either NFP requirement on insurance companies, or a clearly delineated "community service" requirement.

10) Firm up "community service" requirements for NFP entities such as hospitals.

11) Overhaul STARK, EMTALA, and HIPAA to be more clearly delineated and defined.

12) Subsidize COBRA for those losing their jobs.


There are a lot more, really, but that's all I can think of off the top of my head.

_________________
“The duty of a patriot is to protect his country from its government.” - Thomas Paine

sounds good to me,

_________________
I prefer to think of them as "Fighting evil in another dimension"

Could you elaborate on what sort of tort reform you'd like to see?

_________________
"Hysterical children shrieking about right-wing anything need to go sit in the corner and be quiet while the adults are talking."

If I had to guess, a max pay-out 250-500k and the ability to counter-sue to recoup legal fees where a suit was brought with no reasonable grounds.

_________________
The Dude abides.

Tort reform is definately needed. I also agree with DRG's. Making reimbursement directly related to disease inspires hospitals to seek constant improvement in ways to handle things. DRG's can mean decreased revenue if hospitals are not agressive in following the guidelines.

The other issues I have are ethical ones. Should thousands of dollars be spent on certain cases when the outcome is bleak at best, yet we still keep treatment going until DNR status is decided. I go back and forth on these ethical dilemmas.

What type of community service do you envision for NFP hospitals? A balance between paying and nonpaying patients somehow?

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

I personally think the government should purchase catastrophic insurance ($50,000+ deductible) for everyone and beyond that let people make their own decisions. Catastrophic insurance is cheap and there's not much potential for fraud or moral hazards running up the cost when you have to pay the first $50,000 yourself. That way nobody has to die for total lack of care and nobody is saddled with a totally unpayable debt for life.

This seems good, in addition to some sort of statute of limitations.



Charity care is generally what falls under "community service." The problem is that there is no guideline in the tax code to indicate what the threshold is to justify tax-exempt status. I'd probably just advocate either a raw percentage of gross revenue, or (more complicated and thus very much less favored by me) some method of indexing against what their direct savings (from not having to pay taxes) would have been. Indirect savings would be left out.



Taken care of by establishing a minimum for community service. You'd be surprised how little many hospitals give out.

_________________
“The duty of a patriot is to protect his country from its government.” - Thomas Paine

so routine doctor visits would apply to the 50k deductible or would this only apply to extended hospital stays? If people don't have insurance they usually don't get preventative care. Preventative care can lessen the severity and onset of hospital stays. Also people with no insurance tend to wait longer to come in..they are sicker..thus treatment costs more.

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

Hospitals can't refuse your admission based on if you have insurance or not, but based on the location of the hospital the number of uninsured is higher and thus the burden greater. Perhaps having less competition is the key..say 1 or 2 hospitals with many locations..some in affluent areas but also some inner city. Since the money is all from the same corporation this could even out the field by having the affluent neighborhood hospitals putting more money in the till.

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

I continue to be baffled as to why other wise intelligent and rational people believe that "Tort Reform" would do anything to lower health care costs in this country.

In California, they have had a cap on pain and suffering judgments for something like 20 years, and it has done nothing to alter the cost of health care for the better. Doctors continue to practice defensive medicine and they continue to pay high malpractice premiums.

The fact of the matter is that medical malpractice lawsuits are like a tiny drop in the Ocean of overall medical costs. Something like 30 billion of 16% of our overall GDP.

On the flip side, thousands of people lose their lives every year to medical malpractice. I just think it's wrong headed to see that as any kind of solution to our health care woes.

There's really only one good solution - single payer, of some form. Either medicare for all, or a national health system similar to the VA.

_________________


It feels like all the people who want limited government really just want government limited to Republicans.
---The Daily Show

A cap on pain and suffering costs does absolutely nothing to reduce other tort costs, and therefore is little evidence of how effective tort reform would be. It still does nothing to reuce lawsuits because for most people the idea of $250,000 on top of whatever else they would get is still an attractive amount of money.

Real tort reform wouldn't just cap awards but actually reduce ability to sue or penalize lawsuits that had no basis. Really, even if you're dirt-ass poor, if you sue for no good reason you should be paying your pitiful income to cover the legal costs of your frivolous lawsuit. Being poor does not entitle you to use the courts as a way of getting rich, nor to cost other people money in the attempt.

As for single pay, there's no good reason to think it would help at all, much less be the only thing that would help.

_________________
"Hysterical children shrieking about right-wing anything need to go sit in the corner and be quiet while the adults are talking."

You wouldn't happen to have any facts to back that up would you?

Here are some real facts. It's been in effect for 34 years. It limits "non-economic" damages to $250,000. All other damages remain unlimited. It has held down malpractice insurance costs:



As always just because somebody says it on the DailyKos, doesn't mean it's true.

_________________
"Dress cops up as soldiers, give them military equipment, train them in military tactics, tell them they’re fighting a ‘war,’ and the consequences are predictable." —Radley Balko

Bah, facts!

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

1) Direct costs of malpractice insurance are indeed "a drop in the bucket" in terms of national healthcare dollars. Approximately 2-3%.

2) The amount of revenue lost by hospitals, which the President has told us that we should all pay for by adding $1 trillion in spending, is a drop in the bucket in terms of healthcare dollars, approximately 2-3%.

3) For reference, 2-3% is approximately what retail chains lose each year to theft.

4) 2-3% reduction in healthcare expenditures in this country amounts to (for 2007) $.044 - $.066 trillion, or $44-$66 billion.

5) Tort reform, as evidenced by Vindicarre, as well as numerous studies from Texas before and after their reforms, does reduce those costs.

6) Shaving $44 - $66 billion is not chump change.

7) We get it that you want a single payer system. Go make your own thread about it; especially considering I asked for feedback on these ideas specifically, and politely.

_________________
“The duty of a patriot is to protect his country from its government.” - Thomas Paine

DFK

1) Replace the current method of paying physicians under Medicare B and Medicaid to be one that doesn't reflect RVU's and thus put pressure solely on productivity. Create some method of paying similar to DRG's that focuses on the disease or disease-process, rather than the volume of patients.


There are quality measures that are being followed for hospitals in place now. Expanding this would help to decrease costs. For example someone coming into ER with a diagnosis of MI has "Core Measures" that need to be followed 100%, if all the steps are not documented then reimbursement is decreased. For an Acute Miocardial Infarction diagnosis, documented proof of Aspirin within 24 hours of admission, ECG within 10 minutes of arrival, PCI within 90 minutes of arrival. Also, discharge planning is included, there needs to be documentation of Asprin, beta blocker, and lipid lowering medication prescribed at discharge. If any of these steps are missed or not documented within the time frame reimbursement is decreased. Currently Pneumonia, MI, COPD and Heart Failure are the only diagnosis that are followed. This type of pay for quality does seem to be a great motivator. This information is published and the public can access it to determine if the hospital they want to choose for elective procedures. Very good PR and elective procedures are what brings in the money.

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

This is all very true, and while not exactly what I was getting at with the reform physician payment bullet, is another great example of a way to cut some cost while improving quality.

_________________
“The duty of a patriot is to protect his country from its government.” - Thomas Paine

Remove the requirement for hospitals to service emergency patients without proof of payment.

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

you can't do this :p Best you can do is evenly spread the non-payer with the payer population by having the same hospital in both areas so it equals out.

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

Define "can't".

I am unaware of any physical law restricting this possibility.

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

ok you can do this, but how would this "reform" healthcare? "reform" of healthcare includes decreasing cost as well as making healthcare available for everyone.

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

No it does not. Reform includes changing the form.

This would unburden the hosiptals from having to waste time and resources on those with no ability pay while freeing those with the ability to pay from subsdizing someone else. It will drastically reduce wait time in emergency rooms in inner cities and allow Hospitals more easily to refuse service to habitual abusers and jail others for trespassing (those seeking free meds to resell).

This would also foster the resurrgence of of charity hositpials and charitable emergency services since they would have the ability to discriminate in whom gets their service.

This would create disincentive to put off medical care or to allocate funds for doing so or to abuse any of the above systems in order to be discriminated against at the point of charity.

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

So you propose hospitals for people that can pay, and hospitals for people that can't pay? Who subsidizes the charitable hospitals? Government? Wouldn't that just be moving eggs to a different basket?

_________________


Dream as if you'll live forever...
...Live as if you'll die tomorrow

Vivere Senza Rimpianti

How is having one's property forced from them to be used on another "charity"?


Charity means willingly and freely given thus charitable hospitals will exist on the donations of individuals or groups.

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

Even if you got past the moral issues of this, you realize that this lets the hospital owner basically play God, if they can refuse treatment arbitrarily, right? They could wait until the ambulance wheels someone in that they personally dislike and then just kick them out, possibly resulting in their death before an ambulance from another hospital can arrive and get them there.

Yes because all businesses make more profit when they can deny services to individual that pay them.

Even better to get the reputation that you kill people because you dislike them when you are in the business to make people better.

I am sure hospitals will have rules of service and one would be "don't kick people out just because you don't like them"

Is this honestly a criticism or are you just joking - its such an absurd concern that I have to ask.

_________________
"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville