U.S. healthcare

by MooshiMooshi

Along with all of today’s articles on the issues with increasing plan costs under Obamacare, came this article.

Why the U.S. Still Trails Many Wealthy Nations in Access to Care

Despite our stereotype that other countries with more socialized forms of medicine are morasses of long waiting periods and lack of access, it turns out that we are worse on those measures than many other countries. And we pay more to boot.

While Obamacare may not be the most perfect system out there (my own opinion is that if they put real teeth into the penalties, they would fix the rising plan costs in a hurry, but I digress), it is clear that our healthcare system is a mess and it was a mess before Obamacare, and that we need to be moving towards the models used in other industrialized countries (which doesn’t have to be single payer, by the way).

I have one pet theory: I think Americans value healthcare less, at least while they are healthy. Perhaps that is why healthy Germans, Swiss, and Canadians will pay more taxes or pay for their mandated plans, while healthy Americans simply won’t. That of course is what leads to the dreaded death spiral – if healthy people don’t participate in the system, only sick people are left, driving up costs. It seems like other industrialized nations have figured out how to get everyone into the system, but we haven’t.

Opinions?

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253 thoughts on “U.S. healthcare

  1. “my own opinion is that if they put real teeth into the penalties, they would fix the rising plan costs in a hurry, but I digress”

    We’re in agreement.

  2. I agree with putting real teeth into the penalties if we’re serious about making working class people pay for their healthcare. I also agree that Americans value other things (childcare that they pay for or provide themselves, larger houses and larger vehicles) more than they value paying for healthcare, in part because the government has allowed them to make this choice. (In other countries, they tax people to pay for healthcare and their budgets don’t allow for American-style houses and vehicles.)

    I don’t think that ability to get a same or next day appointment is a key metric, and it wasn’t clear if nurse practitioners and physician assistants were included as primary care providers in the numerical comparison. Any robust analysis of healthcare in the U.S. needs to consider how this varies by state or regional area, not just as a national metric. I would like to see how the U.S. fares on treating complex issues (multiple sclerosis, fibromyalgia, cancer, migraines) compared to other countries. My biochemist friend with fibromyalgia says patients in Europe are basically told they don’t have a problem and receive minimal medical care and so suffer much more.

    One of the reasons we have so few primary care providers is that training to be an MD is incredibly expensive compared to other countries (in part because of its duration) and specialist reimbursement is so much higher than primary care reimbursement. Physician salaries, adjusted for purchasing power, are roughly triple what they are in other countries, in part because medicine is a cartel and in part because of the cost of education. Since these salaries are paid one way or another by patients (with patient money, insurance money or tax money), that’s a big factor in costs. The NHS imports a lot of physicians and nurses from India and lets them practice with much less additional training than the U.S. requires, I think.

    I think the trend toward nurse practitioners and physician assistants is a good thing, though in my own life, any question I’ve been able to resolve with those providers has also been answerable by Google- I just need them to write a prescription or (this hasn’t happened yet but could) order a test.

    I’ve been puzzling about what “access” to healthcare really means. I’ve talked about the woman I know with bladder control issues due to childbirth who dealt with them for ~20 years, because their working class family (income ~$40-$50k? while raising two kids) didn’t have medical insurance. Because many ACA insurance options still have multi-thousand dollar deductibles/co-pays, providers will now get paid if someone in their family gets cancer, but she still can’t get bladder surgery unless they come up with that multi-thousand dollar deductible. I’m not sure that “access” to healthcare has helped her that much.

  3. : I think Americans value healthcare less, at least while they are healthy. Perhaps that is why healthy Germans, Swiss, and Canadians will pay more taxes or pay for their mandated plans, while healthy Americans simply won’t.

    It’s the complete opposite. Americans pay a ton of money in the form of forgone wages that, rather than paying them out as salary, their employers use to pay for health insurance. Americans pay so much more because we want the best and don’t want to be told no. A friend’s mother passed away at 96 of cancer and her doctor was all set to do chemo, radiation, surgery etc. She and her son said not to bother, she’d had a good run and it was her time. Most Americans don’t agree with that and want the best, cost no object, care.

  4. Wow, less that 1/2 an hour in and WCE and I are zeroing in on the same number.

    The OECD stat (at least on my quick look) – is quite misleading — Only one fifth the number of GPs as Germany? Half as many as Sweden? Without knowing details of their systems, I suspect they use GPs in places where we use other types of physicians for primary care. That means it is a cost issue, not an access issue. I know in my highly managed care practice, we use FP trained physicians (and NPs, and PAs) for as much primary care as we can. They are flexible and less expensive. In other delivery models (in the US), pediatricians (less flexible) and IMs, GYNs (less flexible, more expensive) deliver a lot of primary care. However, our primary care work force in the US consists of many types of physicians – FPs, IMs, Peds, Gyns. Which makes our gross numbers 250k practitioners, instead of the 95k that the OECD reported. (This doesn’t account for NPs/PAs – positions that don’t exist in many countries).

    In short – in Germany, I suspect you don’t see a practitioner with specialized surgical training every time you want to talk about birth control or the funny itch you have down below.

  5. I think America wants a Cadillac Health Care system for everyone, and settles for providing it for some. In contrast, I think many socialized systems provide Corolla Health Care for everyone. If my kid has a cold, for less that $100, I can go to: one of two Children’s Hospital branded Urgent Cares, about 10 ERs (some with no waiting room! get a stuffed animal on every visit! see the doctor in less than 10 minutes after arrival!), likely my pediatrician today (I’ve never had trouble getting a same day appointment), a Children’s Hospital. I realize that is not everyone’s reality – I live in a major urban area, I have good insurance, ability to pay copays, and savvy enough to navigate the system.

    In some other country, I might have to wait 2 days for an appointment. At which time my kid is probably better.

  6. The only equitable solution is the same solution that we have for children’s education – a basic level provided by the government, but complete personal freedom to go outside the government structure if you so choose. If WCE’s friend had to wait for nine months to get her bladder fixed in a national health system, it sure beats having to wait until she turns 65 and Medicare kicks in.

    There are several reasons the elderly live much longer now than they did in 1960. Inexpensive routine medicines are one reason. Reduction of smoking is another. General prosperity is another. But Medicare is also very important. There are many people outside the work related insurance market who simply let things slide until they turn 65. Many of those elderly knee replacements should have been done years earlier.

    The ACA high deductible system is not all that different from what the average employee gets at work nowadays. Part of our “bubble” is working at a professional level for the sort of large employer, industry, or region in which the out of pocket (premiums, deductibles, costs after the employer’s HSA contribution) are very manageable, and you can opt for a wider network. Employer provided insurance at low levels and in many regions is bare bones and the contracted providers are no better than national health or medicaid shops.

  7. I’ve talked about the woman I know with bladder control issues due to childbirth who dealt with them for ~20 years, because their working class family (income ~$40-$50k? while raising two kids) didn’t have medical insurance. Because many ACA insurance options still have multi-thousand dollar deductibles/co-pays, providers will now get paid if someone in their family gets cancer, but she still can’t get bladder surgery unless they come up with that multi-thousand dollar deductible. I’m not sure that “access” to healthcare has helped her that much.

    To channel Milo for a moment – that’s what our political elite, on both the left and right,agree is the solution: People need to pay a lot more out of pocket to force providers to compete on price. The reality is most folks don’t like that plan at all.

    I would argue that a lot of the rebellion against the political elite is by non-totebaggers. A totebagger loves 401ks and 403bs and ROTH conversions and FSAs and HSAs and ohhh you can shield more of your income with an HSA and isn’t that great. Meanwhile, the great unwashed don’t have the time, energy and cognitive bandwidth to deal with all that.

  8. “I would argue that a lot of the rebellion against the political elite is by non-totebaggers”

    ya think? :)

  9. I agree with Mémé. There should be a single payer option similar to Medicare, but it has to be actuarially sustainable and meet TBD access metrics in all counties/regions. This will mean gradually increasing income taxes and penalties for working class people such that the EITC will effectively become a health insurance contribution.

    It’s not clear to me what healthcare economics will look like, once people who can afford to pay privately for heart surgery/knee replacements can go to the Caribbean, Mexico or India for global prices. One of my observations from paying my NICU bills is that roughly half of what private insurance/privately insured people pay for such care goes to subsidize people who don’t pay at all. In contrast, fertility care was priced predictably and cost effectively. As an example, a hysterosalpingiogram is $400 at the fertility center and a pelvic ultrasound is another fixed price. My friend with high deductible insurance ended up going there for a pelvic ultrasound because it was $2xx with a 5% discount for payment by check at time of service, compared to a minimum of $600-$1000 with local providers, who couldn’t provide a fixed number upon request.

  10. Milo,

    What do you think is the way forward? How is this all going to shake out in terms of policy?

  11. I met a coworker from Canada last month who said he recently had 2 related minor issues from falling. His Canadian doctor would only look at 1 and the second issue required a separate appointment. Seems pretty inefficient to me. Here, if you have multiple issues, the doctor is able to bill more and address them all in one visit.

    I think everyone should have some skin in the game – be required to pay out of pocket until you hit a deductible.

    The problem is insurance on the open market is becoming unaffordable. Premium increases the last few years have been really large in my state and many insurers have dropped out of the exchange. So those of us with employer group insurance are fine and those without employer provided insurance have very expensive insurance plus high deductibles.

  12. once people who can afford to pay privately for heart surgery/knee replacements can go to the Caribbean, Mexico or India for global prices.

    They already can.

  13. I think the trend toward nurse practitioners and physician assistants is a good thing, though in my own life, any question I’ve been able to resolve with those providers has also been answerable by Google- I just need them to write a prescription or (this hasn’t happened yet but could) order a test.

    I agree, for the most part. However, in the past year, both DS and I have have somewhat serious health problems and his pediatrician diagnosed both of them. DS because we made an appointment to see her, me because she was seeing another one of my kids, looked at me and said, go see these specialists and have them check for X. She was right both times.

    NP/PAs can also be really helpful because they seem less likely to need to know what the problem is and are more likely to figure out what system isn’t working and send you off to a specialist.

  14. The message that everyone has to enroll and pay into the system at *some price* is not liked and is a tough sell for the politicians.
    Yes, we do want everyone to be covered and coverage has expanded but it comes with a price. Also, the Cadillac service is not going to be available, it is going to be more like a Corolla.
    My SIL’s labor and delivery in the U.K. Was very bare bones compared to mine. She could have only one family member waiting outside. It seemed like she was in a ward as opposed to a private room. Both of us were adequately taken care of in our respective settings.
    And to Meme’s point in the U.K. If you want a higher service level you can go the private route.

  15. those without employer provided insurance have very expensive insurance plus high deductibles.

    You do know that’s only 14% of those on the exchanges? 86% receive subsides that limit the cost.

  16. “but complete personal freedom to go outside the government structure if you so choose. ”

    Which I believe means some docs “concierge docs” can refuse to take the government reimbursement rate (i.e. medicare / medicaid).

    See, I disagree with this.

    If any med student takes a federally backed loan, or any taxpayer-funded need-based grant, then we the people are supporting their education so the quid pro quo is they have to take all comers as patients without discrimination as to ability to pay or the type of insurance they accept. Forever, I believe. Don’t want to be handcuffed like that? Then fund the medical education privately. Why should we set docs up with essentially licenses to print money without having the ongoing social obligation to provide services that are needed?

    Kind of like when we the people give sports team owners tax breaks / incentives to build / refurbish stadiums and then they (the owners) say, no you can’t bring in your own food. Not in my book. You want the public subsidy? then ticketholders can bring in whatever they want to eat. To limit that is wrong.

  17. “What do you think is the way forward? How is this all going to shake out in terms of policy?”

    I have no idea. I haven’t disagreed with anything said on here.

    I’d like a stronger penalty for not obtaining insurance (currently, as I understand it, not only is the penalty weak, it’s not even recoverable other than a reduced tax refund; if it causes a net liability, the IRS can’t even collect it).

    I still marvel at the Root of Good blogger, the married father of three who, along with his wife, retired on the MMM time-frame with $1.5M invested and lives on less than the $30k in dividends. And since that’s their annual income, ACA subsidies means that he pays like $25 a month for the family’s insurance, probably with super-low deductibles. It makes sense for a normal family of five earning $30k, but man, what a loophole for that tiny frugal demographic. Whereas if I were to retire early, and figure I want $100k in annual dividends, there’d be no subsidies, so I’d need to come up with probably another $15-20k a year.

    If all this works out, great. Can anyone here tell me why Trump’s idea (possessive used loosely) to allow interstate insurance markets is a bad idea?

    And if it doesn’t work out, we’ll probably end up with Medicare for all, and maybe you can buy your own supplemental plan or something. The military was a little like that: you could have Tricare Prime for free, and if a military provider was available, you went there; if not, they sent you private. Or you could pay a little extra for Tricare Standard (the terms make no relative sense), and choose among private providers.

  18. If any med student takes a federally backed loan, or any taxpayer-funded need-based grant, then we the people are supporting their education so the quid pro quo is they have to take all comers as patients without discrimination as to ability to pay or the type of insurance they accept.

    I disagree. We don’t have indentured servitude. And by that argument, everyone who takes any federally backed student aid is obliged to work someplace as the government sees fit.

    Given the massive amount of time I’ve spent in doctor’s offices and hospitals, and with insurance companies in the past year, I would really like to understand how much waste and duplication contribute to the cost of health care. I’m also curious about how much time and expense using primary care providers as gatekeepers saves versus letting people book directly with specialists. Especially given Dr. Google.

  19. We don’t provide health insurance and I strongly suspect that our employees just plan to pay the penalty should they become sick enough to need health insurance.

  20. I’m also curious about how much time and expense using primary care providers as gatekeepers saves versus letting people book directly with specialists. Especially given Dr. Google.

    This is where Ada’s going to disagree with everyone else. On this blog, we all feel bright enough to look up our symptoms and take a guess as to which specialist we need to see. Ada’s going to tell us about the colossal idiots she sees every day in the E.D.

  21. “I’m also curious about how much time and expense using primary care providers as gatekeepers saves versus letting people book directly with specialists. Especially given Dr. Google.”

    I think you all might be charitably but falsely ascribing your own research abilities as lay health care providers to the broader population.

  22. Can anyone here tell me why Trump’s idea (possessive used loosely) to allow interstate insurance markets is a bad idea?

    You’d end up with all insurance companies headquartered in the state with the least regulation. Much like with credit card companies all being headquartered in IIRC South Dakota. In that case, the feds had to step in and regulate when the CC companies introduced universal default and started to randomly change the payment due date in an effort to increase revenue.

  23. Here, if you have multiple issues, the doctor is able to bill more and address them all in one visit.

    That’s not actually true. Most doctors will tell you that they will address only one problem per visit, and no problems at the yearly (“free” per ACA) preventative care visit.

    If your experience is different, it is because you are likely a low user of health care (so the doctor is not concerned about setting a precedent with you), or who sees doctors that are not supervised by the government (such as IHS, VA, title X clinics etc), or who has very well paying insurance (important that the doctor maintain relationship with you), or seeing a doctor who depends on a significant patient satisfaction bonus – or some combination of those things.

  24. Milo and Ada are right that we are not representative of the population. I learned a ton about fertility care options from casual conversations with my reproductive endocrinologist during appointments and advised people accordingly, leading to jokes between us about my status as “my county’s leading amateur reproductive endocrinologist”, since he’s the only real one in the state outside Portland.

  25. our employees just plan to pay the penalty should they become sick enough to need health insurance.

    Pay the penalty if they become sick?

  26. Wow RMS – I was almost there! You’re right. Most people don’t know when their acne needs a dermatologist or their irregular vaginal bleeding needs a gyn, or their chest pain needs a cardiologist. In a private pay system, the orthos, GI docs, cardiologist, thrive collecting from good private-pay patients who don’t need to be seen by them.

    I work in a system where we heavily restrict access to specialists. I don’t worry at all about being able to see one when I need one (not because I can work the system, but because I feel the system is fair).

  27. Rhett’s comment about the failure of the compete on price model is spot on. I don’t think that my progressive cohort (liberal is too washed out a term nowadays) favors that model at all – we like national health or at least medicare for all. Inefficiencies such as waiting for an appointment do not seem to be a deal breaker to me. But the wagging fingers liberals/conservatives talk about skin in the game as if (or because) they never had to choose between seeing a doctor and fixing the car so that they can get to work.

    Any system that results in WCE’s friend having to wait until 65 to have a treatable medical problem fixed (or that sends her to social media to crowd fund her procedure) is a broken system in a country as rich as ours. However, if we had every detail of her life someone on the left or the right with a wagging finger would say, this is all a matter of personal choice – she has too many kids, or she and her husband chose low paying work, or they tithe, or they live in a poorly served area, or if there is any way to blame her condition on some youthful or current or even her parents’ choice lifestyle issue – whatever.

  28. Ada, how much research does your system do on people who were denied access to a specialist but, in retrospect, should have been seen by a specialist? Think Type 1 vs. Type 2 error.

  29. “If your experience is different…” Of your list, these apply to us (DW & me) wrt our primary care doc:
    1) it is because you are likely a low user of health care (so the doctor is not concerned about setting a precedent with you), and
    2) who has very well paying insurance (important that the doctor maintain relationship with you), and
    3) seeing a doctor who depends on a significant patient satisfaction bonus

    I have never been told by him or any other doc that if I want that second or third question / issue addressed it’ll have to be during a separate appointment.

  30. Milo asked
    “If all this works out, great. Can anyone here tell me why Trump’s idea (possessive used loosely) to allow interstate insurance markets is a bad idea?”

    This one is easy. It leads to national insurance companies, all located in one state – whichever state has the least regulations. All insurance will devolve to the lowest level. That is what happened in the credit card market, and is the reason why so many credit card companies are located in South Dakota. So basically it turns the market into a one controlled by one state – whichever one is willing to relax regulations the most

  31. Ada, I ask because my FIL died of cancer in part because his PCP wouldn’t refer him to a specialist for a large growth on his leg and he waited 6 months. The PCP claimed the large growth was due to “stress”. This was in your state’s largest HMO.

  32. I work in a system where we heavily restrict access to specialists. I don’t worry at all about being able to see one when I need one (not because I can work the system, but because I feel the system is fair).

    How much of your ability to see a specialist is due to the fact that you know the right words to use to get care?

    I have started to research concierge care because, one it took me two months to see a specialist as my condition became progressively worse, and two, the specialist we were referred to for my son will not share his lab results with us because he is thirteen. He can’t get them either, because he is thirteen.

  33. takes a federally backed loan, or any taxpayer-funded need-based grant

    Would you also require this of lawyers – all lawyers must provide a certain level of pro bono services? Because everybody has the right to legal services? How about accountants? Must they all volunteer to help the indigent prepare their taxes? Because everybody has to submit a tax return. What about MBAs? Should they be required to provide pro bono business services to start ups?

    I can’t see how the fact that you took out a federally subsidized loan as a medical student justifies everyone getting a piece of you for the rest of your life.

    Anecdotally – pre-ACA my physician spouse’s patient population with no insurance (NONE) was 25%. 25% of the work he did was simply not reimbursed. It was all for free. FREE. This does not include under-compensated work (Medicaid). Post ACA, it’s down to 10%. I know of no other profession that is expected to provide so much in free services, and yet people like Fred think that’s the right thing, because a few federally funded loans 20 years were involved.

    I would never, ever encourage anyone to go into medicine today, and this is part of why. Don’t know if Ada would agree.

  34. WCE – you have some impossible to define variables.

    “Denied access” – that is not documented anywhere, unless a patient makes a formal appeal. A kid this week had a very simple (greenstick) arm fracture. The parent asked to see peds ortho (outside the system). Our internal general ortho said she was comfortable handling the problem. I “denied” the referral, explained the reasoning, the parent seemed happy, and saved the system a few thousand dollars. (We’ve already paid the general ortho her salary and benefits for the year, so additional work costs us nothing). There was no documentation in my note regarding any of this.

    “In retrospect should have been seen” – also impossible to define. Every bad outcome can’t be avoided by a specialist. How do we decide that? Examine all deaths over the course of a year and review the chart to see if a specialist referral would have changed things? Most unexpected bad outcomes have some level of peer review and egregious ones often have root-cause-analysis. I don’t think it is a widespread problem.

    A patient was not referred to a specialist for problem due to oversight (not rationing). Patient is angry because treatment for problem was delayed. Specialist says that the 4 month delay was not relevant. How do we classify that? This is the only failure-to-refer that I am personally aware of.

  35. Under our health insurance we do not need a referral to see a specialist. This far I believe we have only seen them when we actually have needed them. Mostly, for us, and us all here, and our totebag peers, I think the gatekeeping of a referral, i.e. the official kind with a tracking number because one’s PCP office actually entered it into a system, this kind of referral is just more hoop jumping PITA activity. Which is why I like my plan.
    The pcp/ped can say “you should really have a dermatologist / orthopedist / etc take a closer look at that”
    Me: “got anybody particular in mind?”
    Doc: Yeah, get an appointment with Jobe; he’s really the best guy for these kind of arm/elbow soreness issues, but if you can’t get him, anybody in his practice will be fine.
    So then I make the appt myself being sure to say my doc said I should see Dr Jobe.

  36. Cordelia – this is what I meant when I say it’s not because I “game” the system. I really think that the vast majority of the time, people in my system get the care they need (not always the care they want). One child has required specialist follow up outside the system. I have simply said, “I think X needs to see a pediatric x this year” in a message to the doctor and they put in the referral.

    Personally, I rarely refuse specialist referrals when asked. I often suggest them.

    But my system is not-for-profit and has an excellent record of providing good care. So, I realize that my experience may not be at all like your experience.

  37. “In retrospect should have been seen” – also impossible to define. Every bad outcome can’t be avoided by a specialist. How do we decide that? Examine all deaths over the course of a year and review the chart to see if a specialist referral would have changed things? Most unexpected bad outcomes have some level of peer review and egregious ones often have root-cause-analysis. I don’t think it is a widespread problem.

    I don’t know if my family has especially bad luck, or we are incompetent at navigating the system or what our problem is, or if we have different definitions of a widespread problem.

    Examine all deaths over the course of a year and review the chart to see if a specialist referral would have changed things?

    Answering this question would seem to be a no brainer.

  38. Would you also require this of lawyers – all lawyers must provide a certain level of pro bono services?

    Sure, lawyers are granted a monopoly by the government. If you want to end lawyer licensing and let the free market sort the wheat from the chaff then fine. If they want a monopoly then they need to give back.

  39. our employees just plan to pay the penalty should they become sick enough to need health insurance.

    Pay the penalty if they become sick?

    From what they’ve told me. If they need insurance, they can pay a penalty and get health insurance. The penalty is less than the cost of having insurance until they need it.

  40. I am interested in the whole access issue in part because of my frustration in simply getting appointments with the developmental pediatrician that 2 of my kids see. The developmental ped, Dr S, is very good, and she also takes insurance. That is evidently such a rare commodity that it is close to impossible to get an appointment. DS1 had been seeing her for about a year, and had a scheduled appt in October. Because of a conflict, the practice cancelled him out of the appt in September, but could not offer another appointment. Dr S was booked through the end of December. I asked if we could schedule for January but the appointment slots for January were not out yet. They put him on the cancellation list, which basically was “if someone cancels, we will call you and you should drop everything and run over”. Except that we never got a call. Meanwhile, DD was seen by Dr S, who asked us to come in for a one month followup because her meds were being changed. Again, same problem – there were no appointments. So DD ended up seeing someone else in the practice, which was a total waste of time because all that person could say was “you need to see Dr S”. This happened last week.

    So, after DD’s appt, I stopped by the reception desk, where the office person told me that the January slots were now open, but in the one day they had been open, were mostly booked. Aargh! So I stood there, and said, we have to find an appt for DS because you guys CANCELLED him out of his October appt, and he has not been SEEN since July. He needs to see the doctor. I started making her go through each day on the appointment list. She was getting angrier and angrier and insisting that there was nothing to be done. And then, the office manager came over, and said “Her son needs to see Dr S. Give him one of the new patient slots. Dr S needs to take fewer new patients anyway”. And so, we FINALLY got an appointment for him, for Decemberr. Meanwhile, DD got a mid January appt, which is not great because she was supposed to be seen in another month for monitoring.

    I hear this same tale of woe from friends living in other places. It is really impossible to find good specialists in certain pediatric areas who take insurance. People end up waiting for months to see a child psychiatrist, for example.

  41. Cordelia – that’s how I too understand how it works. Do you know if they sign up, pay the penalty and any now due premium, get care, then drop off only to repeat the process again when they next need care?

  42. From what they’ve told me. If they need insurance, they can pay a penalty and get health insurance

    That’s not how it works. They are assessed the penalty every year they don’t have insurance. If they get sick they can only get insurance during open enrollment*.

    * there are some qualifying life events that let you in outside open enrollment.

  43. Rhett – anecdata: I heard on NPR this week that even though there’s supposed to be one of the standard out-of-cycle qualifying events (birth/adoption/death/divorce/loss of coverage) it does not always work that way. Especially if on the application (never having seen one) it’s just a tick-the-box of the qualifying event, what’s to prevent the applicant from just picking the most plausible one and moving on from there?

  44. The thing that bothers me most is that when we talk healthcare reform, we never include tort reform. From the friends that I have in medicine, they all admit to practicing defensive medicine and ordering additional tests, scans etc because they are afraid of being sued or missing something and causing their patient harm. There does not seem to be way to sign off that a provider gave reasonable care. Second, providers protect some of their colleagues who have egregious mistakes because they want to protect their ranks. Finally, we can add in patients who a non-compliant for a host of reasons which include both internally and external causes. I think that tort reform could help balance those three factors and lower costs.

  45. what’s to prevent the applicant from just picking the most plausible one and moving on from there

    If you make a claim the insurance companies fraud department will surely ask for documentation.

  46. Mooshi – it must be a combination of the type of speciality/taking insurance plus a large number of persistent, savy parents trying for an available spot.
    For the seniors in our family, getting seen by a specialist was not a big deal.

  47. TLC,

    It is a combination of state law and the medical office bureaucracy overdrive. There are workarounds for the state law for kids with chronic conditions, but the medical office has decided to provide less information than the state law allows for. This is the primary reason we are looking for another specialist. I don’t see how to teach a kid to deal with a chronic condition without access to his labwork.

  48. Mooshi, can your primary care pediatrician help you? Ours has been wonderful for getting my son in to be seen in a timely fashion.

  49. Examine all deaths over the course of a year and review the chart to see if a specialist referral would have changed things?

    Answering this question would seem to be a no brainer.

    There are 2.6 million deaths per year in the US. To thoroughly examine each chart to determine if an earlier referral to specialized care could have avoided the death would require at least an hour per patient. Where do we find and pay for 3,000 highly-trained people working full time to comb over charts and second-guess the medical providers?

    That doesn’t even begin to address the suffering of people who simply have a delay in care and don’t die from it.

    I don’t doubt that some people are unable to access the care that they need. But an army of Monday-morning quarterbacks is not the answer. I don’t know the answer because I don’t see the problem. Not because it doesn’t exist, but not in the worlds I’ve worked in – high end private care, government care, HMO care – all have had adequate access to specialists, in my opinion.

  50. I don’t know that tort reform is a good idea, or maybe it depends on the type of tort reform. My family has had a fair bit of experience in the past few years with incompetence/don’t give a damn medical mistakes. If something bad happens in that case, the medical practice and the people involved should be punished severely.

  51. I think it is easier for seniors because everyone takes Medicare

    No they don’t. I didn’t have a big problem with getting Mom in to specialists, but there were some I called who didn’t take Medicare.

  52. Cordelia – part of HiPAA was written to guarantee access to records (there was no legal guarantee before that). I have a feeling you are dealing with poorly-trained office staff. Does the MD also say that no information can be given to you?

  53. Does the MD also say that no information can be given to you?

    Yes he did. He said that he was scolded for releasing my son’s lab results to the online medical record and that he couldn’t do it anymore.

  54. The thing that bothers me most is that when we talk healthcare reform, we never include tort reform.

    No one can sue Wells Fargo because when you sign up for an account you agree to arbitration and to not bring class action suits. Has eliminating the ability to sue banks resulted in a dramatic decline in fees and higher interest rates on savings? I think the evidence that consumers benefit from not being able to sue is pretty weak.

  55. It is also interesting that everyone assumes that our system must be either “total free market” or “single payer”, when most countries that run successful healthcare systems do neither. I don’t know of any country with a well functioning healthcare system that uses a completely free market model, which makes me wonder why conservatives want our country to be a guinea pig for an untested solution. But at the same time, not that many countries use single payer models, and the ones that do are often not as successful as the countries that use highly regulated private insurance systems. The main single payer countries that I can think of are Canada, Italy, and the UK. The French, the Germans, the Dutch, the Japanese, the Swiss, all use systems based on some mix of private (sometimes non profit only) third party payers, highly regulated, and highly subsidized by taxpayer money. These systems work. Obamacare is a halting. tentative move towards that kind of system. I would like to see it strengthened and made more like the European variants, because darn it, they work!

  56. “Has eliminating the ability to sue banks resulted in a dramatic decline in fees and higher interest rates on savings?”

    Possibly. It’s kind of remarkable how we take for granted free checking, free ATM access, 0% or 1% car loans, low mortgage rates…

  57. If something bad happens in that case, the medical practice and the people involved should be punished severely.

    And my PTSD just flared up.

    I’m out.

  58. My understanding is that tort reform was passed in Texas some years ago, and has had no effect on healthcare costs there. I know I saw some studies on this, but now I can’t find them

  59. , 0% or 1% car loans, low mortgage rates…

    How much of that is due to low interest rates in general?

  60. One thing I find interesting in the healthcare discussion is how personal situations change beliefs of what should be.
    It’s easy for many finger-wagers (I’m really thinking of right side politicians here) to say something along the lines of no to Medicaid expansion / embracing the exchanges until one of their grown/married kids who do not get health insurance thru their/spouse’s employer can’t afford the treatment needed because they are uninsured. Then, all of a sudden, some type of government-sponsored insurance / single-payer for all is a good thing.

  61. But the wagging fingers liberals/conservatives talk about skin in the game as if (or because) they never had to choose between seeing a doctor and fixing the car so that they can get to work.

    The wagging fingered wonks are also almost always people who were blessed with extremely high levels of executive function. They got to where they are because they were good hoop jumpers and they unsurprisingly figure the way to reign in costs is to add more hoops. They can’t really understand what it’s like to be one of those who isn’t a naturally gifted hoop jumper.

  62. Ada – please stay and play.

    What Cordelia said was “experience in the past few years with incompetence/don’t give a damn medical mistakes. If something bad happens in that case…”

    She was not calling you out. Knowing you as well as I do, I think you are well outside both of those camps, as are >99% of all docs. But some have reached a level of incompetence and some others may no longer give a damn. They need to be weeded out of the system. (No different from any other line of work lawyers, teachers, plumbers, taxi drivers etc btw.)

  63. “How much of that is due to low interest rates in general?”

    It’s a big part of it, of course, but banking services are extremely inexpensive, they have been for a long time, including interest rates were much higher, and the services are cheap or free even if you don’t maintain a high balance (where one might suspect that the low rate they pay you on savings is making up for the checking and processing costs.)

  64. Cordelia, not one I can find and link. So call it anecdata. But I remember hearing about it. Maybe it was just something around here.

  65. The way it works for gaming the system at the “free” annual physical under ACA is that they code in a couple of extra services to try to get paid. One year they charged 25 dollars for the four line depression screening piece of paper, that didn’t get disallowed by the insurance company and I had to pay for it under the annual deductible. I chose not raise a stink since they practice is very accommodating and local. However, the companies got wise to that and if an extra code is provided, say for a respiratory test – 30 sec administered by the office med asst, they now disallow the separate charge with no patient responsibility as a bundled service that should be included in the visit. It is money – the reason the doctor makes you come back is that it counts as two visits.

    Mooshi’s problem with the only ped specialist who takes insurance is a supply and demand problem. I don’t think even if we went to a national health or single payer system we would ever forbid people to go outside the system within the US if they wished to pay, or forbid doctors to practice and refuse insurance for their personal services. Hospitals might refuse them admitting privileges, but that is not always relevant to the specialty. In some centralized socialist democracies that is sometimes the rule, just as it is for education – home schooling not permitted in Germany, for example, or choice of primary language of instruction in Province Québec.

    Others have answered the across state lines problem – but there is a bit more to it. Use of Credit cards issued by out of state companies fall under interstate commerce. Health regulation, professional certification, insurance regulation are considered matters that default to the state under the Constitution. Conservatives often talk about regulation at the lowest level of government being the best, with some justification. Social matters, education, resource management, community standards, liquor/marijuana, definition of marriage, education, agricultural regulations, etc. However, when it comes to commercial matters, they invoke interstate commerce and want the least restrictive common denominator in force nationwide. It just depends on whether you think health and other insurance standards or professional licensing are restraints on trade or matters reserved to the states.

  66. Ada, for what it’s worth, the PCP who refused to refer my FIL stopped practicing with that HMO group soon after, I suspect in part of complaints like my FIL’s. My FIL observed a difference in competence between his Seattle physicians and his eastern Washington physicians, with some eastern Washington specialists less competent.

    I remember one case where he asked the Seattle radiologist to review a scan where he disagreed with the assessment of the eastern Washington radiologist and the Seattle radiologist found cancer where my FIL did and the eastern Washington radiologist called the scan clean.

  67. @Ada – that’s interesting that “Most doctors will tell you that they will address only one problem per visit, and no problems at the yearly (“free” per ACA) preventative care visit.”

    Is the preventative care visit just supposed to be an exam and routine tests (cholesterol, etc.) that are non-specific to any problems you have?

  68. I agree with Ada that for anyone who is sick enough to die, it’s hard to tell whether medical errors affected the outcome, in part because the amount of medical care anyone who is sick enough to die receives means at least some medical error along the way is a statistical certainty.

    My judgement of cancer care for patients with likely terminal cancer is that patients who have the executive function to recognize medical errors are at a huge advantage.

  69. My judgement of cancer care for patients with likely terminal cancer is that patients who have the executive function to recognize medical errors are at a huge advantage

    I suspect this holds true for anyone with a non trivial illness.

  70. I know I have told this story before, but my DS was misdiagnosed for months, a period during which he became sicker and sicker, and we became more and more desperate. He was a textbook example of an abdominal tumor, and even I had figured it out. Yet the pediatrician could not, and kept insisting that he just had a virus. He was even admitted to a major teaching hospital, one that trains a large number of US pediatricians, for a week, and still no one figured it out. Worse, no one wanted to run the tests that would have diagnosed it. He was seen by a number of specialists while in the hospital. He was even examined by the head of the pediatric service. So the problem was not that we couldn’t see specialists, but rather, a gatekeeper mentality in that particular hospital and among the affiliated pediatricians. They were afraid to run a CT scan or MRI because they kept saying it wasn;t indicated. Excuse me, a toddler with obvious severe ascites, intermittent fevers, not eating, severe loss of weight, and severe anemia – and a CT scan isn’t indicated????

    They finally relented when my kid got to the point where he looked like he was dying. They ran the d*mn CT scan. I am sure the notes said “at the request of the crazy mother”. And they found a large abdominal tumor. Fancy that.

    We transferred him to MSKCC where they said he was end stage and would have not made it another week. The onc always joked with me that I was the mom who diagnosed her own kid via the Internet. But he also said that the other hospital, the one that trains a large number of pediatricians in the US, was grossly incompetent in this case. It was nothing we could do anything about, because once my kid didn’t die in that first week, his course of treatment and chances were the same as if he had been diagnosed on time.

    In any case, the issue for us was not lack of access to a specialist, but rather, doctors who seemed to be terrified that they would be dinged by the insurance company for ordering unnecessary tests

  71. In any case, the issue for us was not lack of access to a specialist, but rather, doctors who seemed to be terrified that they would be dinged by the insurance company for ordering unnecessary tests

    Yes, and it seems like there are certain time periods when it is much harder to get diagnostic tests than others.

  72. The preventative care visit is intended to check vitals and blood work (and the definition of vitals increases in scope with age), general physical assessment with your clothes off. A woman can get her bc prescription renewed. My doctor offers a gyn exam at that visit as well if you want, but I think that is an extra service charge. I always get my blood work in advance because I have the freedom to do so, some patients get it at the visit and get a call back if anything requires follow up. Certain other things are at no charge to the patient under other parts of ACA or Medicare, so a fall visit will include a flu shot. Vaccination updates, including shingles, pneumonia, DPT.

    A great cost savings to all would be relaxation of the one year validity of prescriptions or a commonsense decision for docs/PAs to renew some things without a visit – is that national or just MA limitation on validity – many docs won’t renew without an annual visit. For eyeglasses in MA the opticians require a new prescription every two years. There is no statistical reason a healthy 23 year old guy needs to go to the doctor for an annual checkup, but some employers require it and we get in the habit, and statistics are not the same as finding a disease early in your adult son.

  73. Does anyone have an idea how much unnecessary requirements (for physicals for camp, doctor’s notes for medicines, etc.) contribute to medical costs? My state annoys me by requiring a doctor’s note for OTC medications at school, including cough drops.

    At least at my child’s school, a note from the parent saying that “Dr. X recommended yy” is accepted, but I can imagine principals who don’t have 6 children of their own being less lenient. One of the reasons I like my pediatrician is that he categorically recommends hydrocortisone cream when my child has eczema, I can write a note, and if he’s ever called, he recommended the hydrocortisone, even if he didn’t see that particular bout of eczema.

  74. Interesting counter-argument to allowing interstate competition for health insurance.

    “You’d end up with all insurance companies headquartered in the state with the least regulation.”

    I’m not sure why the federal government could not grant itself the authority to impose some bare minimum regulations and requirements.

    Another specialty that I’ve found has limited access (long waits for appointments) is dermatology. Maybe it’s because many of them are kept exceptionally busy doing Botox or similar treatments. And I have been told, by a dermatologist, that I’d have to make another appointment for a specific condition I brought up at one appointment.

  75. I’ll sing again the praises of Oregon’s decision to allow pharmacists to prescribe birth control pills.

  76. I have to see my GP once a year to get my BP med prescription renewed. It is a PITA because I have to set up the appointment way a couple of months in advance since it is a well -person visit, and I have a tendency to forget to do it in time.

  77. CoC said “I’m not sure why the federal government could not grant itself the authority to impose some bare minimum regulations and requirements”

    I am sure that could be done. But wouldn’t conservatives then howl at the federal takeover of insurance?

  78. Rhett –

    The acceleration on the Corolla just doesn’t cut it for me – not good merging in on the Rte 2 hill or in my hilly town – but I love the price and standard features. I will need the Camry. And the safety features are why I am going to bite the bullet next spring. Driving gets harder every day, especially at night. And babysitting the grandkids involves driving in the dark or spending the night. I’ll take the former.

  79. Does anyone have an idea how much unnecessary requirements (for physicals for camp, doctor’s notes for medicines, etc.) contribute to medical costs?

    I wonder that too. I have been SOOOO tempted just to sign something on those forms.

  80. Meme,

    I got a used 2011 Camry a few years ago. Its a great car. Sorry Rhett and Milo, but I’m not planning on doing much shopping between car models when I replace it. I think I’m turning into one of those people who says, we’ll just get newer version of the same model I have now.

  81. “But wouldn’t conservatives then howl at the federal takeover of insurance?”

    Very possibly, but they may be placated by understanding that compared to ACA as it stands now this federal intervention is minimal.

    Speaking of living in the future, I just learned that some clothes dryers come with NFC tags that allow you to program through your smartphone. I’m told this feature is not used all that much. I’m waiting for the tag that puts the clothes in and takes them out and folds them . . .

  82. Mooshi – I would have lost my mind going through that.

    Rhett – Interesting. Electronic technology does filter down quickly.

    Meme – I’m sure that whenever the next iteration of the Camry comes out, it will have the same thing.

    My two old cars are going strong. I was proud of myself for changing out a dead battery all on my own the other day. WCE is rolling her eyes, I’m sure.

  83. I may have to buy another vehicle if they come out with one that senses cyclists riding the wrong way in the rain at night with no lights or reflective clothing. D*&^ college students think they are invincible.

  84. I may have to buy another vehicle if they come out with one that senses cyclists riding the wrong way in the rain at night with no lights or reflective clothing.

    They already have that:

  85. Sue it cues you to jam on the brakes and then adds “brake assist”, so you’re slammed into the seat belt and shoulder harness. Hmph.

  86. Mooshi, you’re exactly right.
    Another thing I value in a public single payer system where everyone has insurance is just that–there is never a question or hassle about it. I fell, hit my head, was taken by ambulance to get stitches, and seriously can’t recall if I was asked for my insurance card or if they just looked my policy up by my name. (That was in the mid 90s). Today we are in a bit of a bind. We are in between insurance companies, so I figured I’d pay out of pocket for a sick visit to the pediatrician. Turns out mono tests are over $700. So we’ll wait a couple days for insurance to kick in before having that done. It’s annoying, but obviously nowhere near the life or death situation it could be. A blanket policy for the whole country would avoid such issues.
    While we’re at it, I also appreciate the way Germany’s labor laws cooperate with health insurance. There is no limit on the number of sick days a person can take annually. If you are sick for more than two days, you need a doctor’s excuse. So people are less likely to work when they are sick, and most likely will see a doctor when they are sick. Is the system abused? I’ve heard some people grumble about others being “sick” on days that are predictably busy, but compared to the issues that having people work when they are sick–getting sicker, spreading the illness, doing poor work–I think the costs are probably about the same. And I doubt it happens at higher-level professional positions.

  87. DS is already angling for a new smart car. He seems to have been listening to Finn’s safety features benefits for new drivers. He uses it as a selling point as to why a new car would should be presented to him. He is still couple of years from driving but it never hurts to state ones preferences in advance.

  88. S&M, what do you think the benefit of seeing the doctor is when you are sick? I’m asking in part because I’ve gone to the doctor for sickness twice in the past ~20 years.

  89. Sue it cues you to jam on the brakes and then adds “brake assist”, so you’re slammed into the seat belt and shoulder harness.

    At the point it slams on the brakes, if it weren’t there you’d hit the seat belt when you rear-ended the car in front of you. In the Audi, it also yanks the seatbelts tight to minimize the forces on the body before the impact in case it can’t stop in time.

    Also, you car probably already has brake assist. They found that when a crash is imminent people hit the brakes, but not at full force. As the obstetrical gets closer they really hit the brakes. To deal with that, most cars detect a panic stop by the speed at which you depress the pedal and determining you’re panic stopping, they apply full braking force.

  90. Meme, not sure if the checkup for a healthy 23 year old you mention is an eye exam or general physical, but I am certain that if that person develops glaucoma or another irreversible health issue in that year, he will be very glad to have it detected relatively early. And how did you come up with “no statistical reason” anyway–are you spitballing the figures for conditions which get worse when not caught early, or do you know them from somewhere?

    I agree with those who have sad that pro forms one year Rx expiration dates are silly, but there are certainly valid reasons to have people get an annual physical, even (especially!) for those who think there is no way anything is wrong.

  91. S&M, what do you think the benefit of seeing the doctor is when you are sick? I’m asking in part because I’ve gone to the doctor for sickness twice in the past ~20 years.

    If you have an illness that likely won’t get better without treatment, then the benefit is that you get well. (my illness earlier this year) Or, if you have an underlying condition that flares up with an illness (e.g. asthma) seeing the doc for treatment/meds can tamp down the condition so that it doesn’t get worse.

  92. WCE, how long were you sick the times you went to a doc, and what’s the longest you’ve been in bed sick without seeing someone? People who are sick in bed for three days or longer probably have something more than a passing bug, so getting treatment is beneficial. And of course having to have a doctor certify that you’re sick cuts down on abuse of the sick leave policy. With four kids and a husband who travels, I am sure you see the need for letting people take the number of days actually needed to stay healthy (not just alive).

  93. Mooshi, your story about the teaching hospital is horrifying. So glad your son got what he needed in the end, but how awful to be so helpless.

  94. I was sick for ~3 weeks before I went to see a doctor for 1 of ~13 bouts of mastitis- the last week of my bad bout, I was so sick I was alternating ibuprofen with acetaminophen to deal with the pain/fever. I went to work and cared for kids as usual. (Mr WCE was in Europe for ~2 weeks of it)

    I had chronic bronchitis for ~1 week before I paid $500 for tests to determine I had chronic bronchitis and not pneumonia, and that I should rest, drink fluids and take acetaminophen for the fever. (no prescription needed). I rested as much as a feverish mother caring for children 1, 1 and 3, who are intermittently sick themselves, reasonably can over the next few days, but the $500 to determine I did NOT have pneumonia had no benefit to my health, because I didn’t have pneumonia.

  95. I wonder how much savings in health care costs could accrue from being able to self sort/self prescribe certain meds? At this point, I suspect that both WCE and I can diagnose ear infections, determine when to escalate the asthma meds, and have a decent idea what relatively simple meds are necessary?

  96. WCE – whoa. I had mastitis twice and the first time, I went from fine to 103 fever in 24 hours. No way I could have waited for 3 weeks. The second time I called and was very insistent on the phone that I had it, I had just had it, please call the prescription in already, so I didn’t have to drag the 8-week-old in to the dr.

  97. WCE, if you had chronic urinary tract infections, you’d see the doctor more often. I did (many years ago) finally find a urologist who would let me refill the script with just a phone call.

  98. L, I get weird mastitis around an existing lump where the fever and pain kind of comes and goes, so it isn’t a “typical” mastitis. Part of why I took so long for me to decide to go to urgent care is that I couldn’t get an appointment with my regular provider (who could also evaluate the baseline change in my lump) and I hate dealing with the urgent care by my house. (Bad experience with the bronchitis…) It turns out I like a different immediate care and so would probably go there for a future illness after ~1 week and not 3 weeks.

    Note that I have gotten over the other dozen plus cases of mastitis without seeing a physician.

  99. I think the yearly visit even for healthy people just gets you in the habit of going to the doctor. In the home country, there is just a culture of not visiting the doctor, even if you can afford it. Many of my parents friends as they aged thought they were fine but have been harboring conditions which could have been controlled. These have resulted in far greater problems, than they ever thought.

  100. I wonder how much savings in health care costs could accrue from being able to self sort/self prescribe certain meds?

    Antibiotics should always be tightly controlled and a case can also be made for narcotics. That said, I think the number of drugs that you can buy over the counter should be much larger than it is.

  101. One of the things I always think may drive up health care costs are daycare and school policies. An example is the use of antibiotics for ear infections, which doctors are not supposed to do on a routine basis. The problem is, most daycares have a policy that you can send your kid with an ear infection back to daycare 24 hours after starting an antibiotic. So if you are a parent who really can’t take off work for several days to do the watchful waiting we are supposed to do with ear infections these days, you are going to push for an antibiotic to be prescribed. Another example is the need for doctors notes in a lot of schools to get your kid back in. I have had to make many appointments at the ped to get notes stating that the kid’s rash/allergic cough/boil, etc, is not contagious. The ped always rolls his or her eyes in amusement and signs off. It is clear they do a lot of this note busines.

  102. “I’ll sing again the praises of Oregon’s decision to allow pharmacists to prescribe birth control pills.”

    This should be national. It’s ridiculous. They are OTC in Europe (from a pharmacist).

  103. “Another example is the need for doctors notes in a lot of schools to get your kid back in.”

    What happens when someone challenges this? Like, just put your kid on the bus in the morning. If they call you, you say “No, I’m not picking him up. He’s fine.”

    Alternatively, “our religion doesn’t allow medical treatment for these things. You’re a public school, he’s going, and he’s staying there.”

  104. Pharmacies in countries like Germany and France have a different role than here. In those countries, the pharmacist is more central to healthcare and can make decisions on whether to give a patient certain drugs without a doctor’s order. It is weird because you have to go to a pharmacist to get drugs like aspirin that we get at Target or the gas station, but you can also get drugs that would normally be prescribed by a physician at that same pharmacy.

  105. Public schools have the right to exclude children from the classroom in certain cases (think of suspensions) and health policy is one of them.

  106. I never go to the dr. when sick – honestly can’t think of a time I did since living in Atlanta for 13 years except when I got sciatica when pregnant with my youngest. The physicians assistant wanted me to go to PT but I took some hot baths and did the stretches she gave me and it went away. I definitely had mastitis a few times with the last two kids and just took some advil and used some hot compresses and it resolved. I do go for physicals and annual appointments but ear aches/sore throats/fevers are usually viral. My PC is going the concierge route but since we’re not big medical users at this time we’ll likely just find a new PC.

  107. My curiosity got to me and I finally googled mastitis. And here I was thinking it had to do with the gums or something else in the mouth, but I can see where I went wrong in assuming that.

    We go to the doctor a lot more than some of you all. Maybe we’re have some hypochondriatic tendencies.

  108. CofC we go to the doctor a lot more than others as well. We did even before this year when we started going almost weekly.

    For you people who don’t go to the doctor very often….doesn’t anyone in your family get hurt? In the past three years, we’ve had two broken bones, gas splashed in someone’s face, stitches from a kitchen mishap, other random injuries. And it’s not just the kids, the adults join in on the mayhem as well.

    And I thought we were so much safer than my family of origin. I still remember being shocked that my college roommate had never had stitches and none of her sisters had either.

  109. Random PSA: Youtube appears to have quite a few of the “BBC Play of the Month” episodes from the early 1970s. Lots of classic plays with well-known British actors.

  110. Cordelia, I have never had stitches, nor broken a bone or even sprained anything. Two of my kids have had stitches, but none have ever broken anything. I attribute the lack of breaking bones to the fact that we don’t ski.

  111. On Monday my oldest was using scissors and sliced her thumb. This occurred 30 minutes before trick or treating. The closest urgent care is not in network, and it isn’t a true emergency so going to the always empty ER at the local hospital probably would result in a huge bill. I then spent about 5 minutes trying to log into my medical plan website (reset password) to see if the local urgent care actually is in network (it isn’t). With rush hour traffic it would take 30 minutes to get to to the in network Urgent Care. We opted to wrap it tightly and sent her on her way. Bleeding did end up stopping by the end of the night. It does seem ridiculous that the cost of treatment was on my mind at the time that blood is gushing out of her tiny thumb….and I have the money to cover it.

  112. I’ve never had a broken bone or stitches due to an injury. I once stress-fractured my knee in high school during a race, couldn’t put any weight on it and had to hop to my Dad’s car with arms around two sets of shoulders, and I was on crutches for a few weeks.

    With my kids, we had one partial finger tip amputation (that’s what the ER paperwork said) from a swinging crib gate, and that got all sewn up, one fall in the yard that required a couple stitches on a knee, and one front tooth with the upper half broken off (adult/permanent, unfortunately) while on vacation that didn’t really require the out-of-state dentist I found online to open his office at 9 pm on a Saturday night, but we were scared about it and he did so, anyway, and did an amazing job with a compound/bonding repair that you can’t even tell the difference. It can supposedly be replaced by a permanent crown at 18.

  113. I’ve had BC prescribed by a doc in Germany, never heard of it being prescribed by a pharmacist. But I do know that pharmacists in the US know an awful lot about drug interactions and how each med affects your body, and are usually happy to talk about it. I don’t see why going to the gyno once a year is such a huge problem, if you have health insurance and work policies that encourage good health. I haven’t been on BC for years, but still get an annual check-up. Then again, I’ve had a couple bad paps and had to have some cells removed twice, so I may be more at risk for or more aware of cervical cancer than many women. Breast self-exam is possible, but I’m always glad to have someone more practice check my work, and palpitating your own cervix (or even having your partner do it for you) is much more difficult.

    Atlanta, sounds like you and WCE are in the same happy boat–rarely sick for more than a day or two in a way that causes you to miss work. Is that right? Most doctors whose policies I know generally don’t want to see anyone who’s been sick less than three days anyway. How long did the mastitis keep you from your regular activities? I think of that as a thing that resolves within a couple feedings, so less than one day, but I may be an outlier there.

    WCE, you must be joking–no benefit to knowing you didn’t have pneumonia? Ever hear of the concept of risk and how it relates to price? One of our finance whizzes can explain it to you.

    Cordelia, lol, I’ve diagnosed ear infections in my kid, including the very first one, for which it was difficult to get an appt because neither the receptionist or nurse believed it to be an ear infection, based on my description and how quietly he was crying while I was on the phone with them. The doc took one look and said the eardrum looked ready to burst. He also occasionally gets the respiratory infection trifecta of ear infection, bronchitis, and sinus infection. I’m pretty good at figuring out that’s what’s going on, but still don’t see why you would have a problem having someone trained in this stuff take a look and listen (and possibly a chest x-ray depending on how gurgly things sound down there) to make sure that’s all that’s going on. The kid’s miserable enough as it is when all that pops up; I sure wouldn’t want to prolong his misery because there was something else I missed that a thorough exam would discover. And I want public health insurance so that every person’s kid has the same benefit, even if their parents do not have your skill in Dxing ear infections.

  114. Milo, how long ago was the tooth repair? My kiddo’s lasted probably 1.5-2 years. Apparently they do fall off as the kids grow. We’ve opted not to worry about getting more until he’s applying for things that require interviews (it’s his front top teeth)

  115. I’m pretty good at figuring out that’s what’s going on, but still don’t see why you would have a problem having someone trained in this stuff take a look and listen (and possibly a chest x-ray depending on how gurgly things sound down there) to make sure that’s all that’s going on.

    SM, the doc’s office is a 45 minute drive away. That is 1 1/2 round trip travel time. Plus the waiting time. And, it has not been my experience that the doc/PA/NP you get for the same day appointment is necessarily all that thorough.

  116. Cordelia, that’s how far ours is too. We use the CVS that’s 10 min away for this kind of thing that has become routine for us. Next step is the urgent care, where there are MDs and an x-ray machine. Two visits there last week for the same thing, and they said if it didn’t resolve, then go to his pediatrician, so we did today. The providers we get are usually friendly and willing to do what I ask them, so I do so in a friendly tone if they seem to be skipping something–“with his asthma, he tends to get infections in his lungs. Could you give them a listen?” And then once they know you’re watching, suddenly they are much more thorough.

  117. saac – It was early this past summer. We ended up driving to a dentist in Danbury, CT. God, what a beautiful area. Except all the gas stations close after dark, and you can’t even pump gas with a credit card. Craziness. I got back on fumes.

    They warned us that it might fall off, and I misspoke. It’s a top, front tooth, and it’s truly the full lower half of the portion outside of the gums that disappeared.

    This may be bubbly, but I think insurance paid half and it was only a couple hundred dollars for our share, so I imagine we’d just do another compound if necessary until it’s fully grown and ready for a crown.

  118. Oh, sure, we’ve had broken bones (mostly fingers, but a leg, clavicle, boxer’s fracture too), two appendectomies, a few stitch-requiring gashes. Just last week I went to the hip doc and got ok’d to get on the list for a resurfacing or replacement, my choice, whenever I’d like it after April (surgeries booked till then, and I’m not really in that much pain, so it will be next year sometime). But re illness, except for the appendicitis, we’ve been pretty fortunate. And nothing very major in the last 3 years.

    I’m picking the resurfacing. Longer recovery but I can get back to jogging and playing 1/2 court basketball. A replaced hip, I’m told, cannot take the pounding.

  119. Milo said ” It was early this past summer. We ended up driving to a dentist in Danbury, CT. God, what a beautiful area. Except all the gas stations close after dark, and you can’t even pump gas with a credit card.”

    I used to live there. Lots of gas stations open at night, and of course you can use a credit card.

  120. Mooshi – I went to four gas stations. They were all closed on Saturday night, around 10pm. Closed, dark, pumps turned off, can’t even use your credit card to pay at the pump.

  121. Milo, I think I paid even less out of pocket. But this boy sees doctors often enough, including frequent allergy shots and dental check-ups twice a year. I don’t see the need to pile on hours at the dentist.

  122. Mooshi – I’m wondering if there’s a new state regulation since you left that perhaps requires an attendant to keep a gas station open, and it’s not worth it in more rural areas.

  123. You must have been in a strange area. Danbury is not rural. Perhaps you were in Litchfield County, just north? That is an area inhabited by extremely wealthy people who like to play at being rural. They probably don’t allow gas stations to be open at night because it might ruin the “rural ambiance”.

  124. Fred, you might want to double-check that. My dad is probably not as vigorous as you, but within three months of his hip replacement in his mid 70s he was biking off to his regular tennis group.

  125. Lots of gas stations open at night, and of course you can use a credit card.

    He might not know where to go. I know around here, depending on the location, gas stations aren’t open late. I think it’s probably a economic issue, there just isn’t the volume of customers after 10pm to justify being open.

  126. “the doc’s office is a 45 minute drive away.”

    Well, since we have an urgent care and two drugstore clinics within about half a mile away, and then a hospital and many of our doctors within about 2 miles, maybe that makes it easier to decide to let a professional check out that ache or cough or whatever. Reminds me, I need to get my flu shot at the drugstore clinic.

  127. Possible. But his description still sounds more like Litchfield. Danbury is a large, fairly dense town with a population of about 80,000. It has a big mall, and a university with two campuses. Every big box store you can think of has an outlet there. It is also the town where Stew Leonards started

  128. CoC, is that urgent care any good? I used the urgent care facility associated with my GP’s practice, which is really good and almost never a wait, so I haven’t checked that one out. Never tried the CVS either. My kids go to the pediatric urgent care in mamaroneck.

  129. @MM – I’m chuckling at your description of Litchfield County. Haven’t been there in 15 years, but it seems very accurate. A few New England Rednecks around too.

    I find having to go to the OB/GYN every year to be a huge PITA when pap smears are only recommended every 3 years now. I don’t think hauling in there for her to do a breast cancer self exam now that I am old enough to require annual mammograms anyhow is all that useful. That’s about all the visit is without a pap. Just renew my BC prescription which has been the same for almost a decade, put in the order for the mammogram with the imaging center, and have me come in for a followup if necessary. It could all be done via the hospital/clinic network’s online system which I find to be great for communicating with doctors & viewing test results.

  130. MM, that urgent care is alright, but it has misdiagnosed some ailments. My GP also has an urgent care that I like. They’re located in Scarsdale so I have gone there. I wonder if we use the same practice. I really like them. I really, really like my doctor.

  131. CoC, no, but my husband may be using that practice. I go to the mega practice that has 3 urgent cares in Westchester, including the one over in the weird shopping development on the hill in Yonkers

  132. Towards the end of our pediatric years, the trend with minor illnesses such as ear and upper respiratory infections, was the whole watchful waiting thing, which was fine with me provided that the doctor agreed to write a prescription for antibiotics that I would fill only if the symptoms didn’t resolve after x days. And they were usually fine with that approach too. No matter how well they tried to segregate the sick and well waiting rooms, I was convinced that my kids (and I) were going to pick up more serious germs while we were there getting minor stuff checked out. Certainly, the non-sick kids who had to be dragged along were exposed to more germs than they needed. There was a whole elaborate calculation every time one of the kids was sick, especially because our pediatrician’s office was at least 25 minutes of unpleasant traffic away.

    I don’t miss those days.

  133. “I don’t think hauling in there for her to do a breast cancer self exam now that I am old enough to require annual mammograms anyhow is all that useful.”

    Based on my experience with a breast cancer diagnosis less than 6 months after a clean mammogram, I respectfully disagree. A doc or nurse who does dozens of breast exams a week might well pick up something that you miss yourself, even if you are very diligent with self-exams, which many women unfortunately are not.

  134. I attribute the few visits to the doctor a year for my kids to them being in daycare with its softer surfaces and watchful teachers. They did contract colds, had fevers but all of that was Tylenol every four hours and should be gone by Day Three variety.
    We live five minutes from our pediatric practice. It so happened that they moved from a 20 minute drive to close to us. We also have satellite medical buildings of our biggest health care system dotted in each area so the drive to an urgent care and many medical providers is not too far. For the seniors in our family, the CVS minute clicnic has worked well if we just want them checked out for small issues.

  135. It was driving between Danbury and Trumbull, so no direct highway route (I don’t think), because my phone routed us differently between coming and going, and it was rural for most of it. But even the big gas station near the hotel (and a bunch of restaurants) in Trumbull was closed.

    Next time I’m calling Mooshi.

  136. My theory of being sick is that I’ll either die or I’ll get better and if I can’t rest (because of my child obligations), having a doctor tell me to rest doesn’t really help. So far, I haven’t died.

    We’ve had one round of stitches for a cut to the back of someone’s head and one ear infection that included a ruptured eardrum and antibiotics. I’ve gotten better at managing ear infections since I’ve learned to alternate ibuprofen with acetaminophen so I can treat pain more often, in case any new parents are reading today.

  137. Milo I would have to drive from my home 4 or 5 miles to find a gas station open after 10 pm. Only by the highway.

    I make little use of doctors other than a complete annual physical and plan to discontinue routine scan testing in my mid 70s, but I do like to rule bad things out when I have a question or detect a health change. My child’s fatal illness 37 years ago makes me a bit nervous. I have been very healthy and my non routine encounters with the system have mostly been ob gyn. My semi feral kids had multiple broken bones and stitches. Most other symptoms resolved with time, not treatment even when we went in for an appt. I keep everything on hand to manage colds and aches and first aid issues. DH uses enough medical care for a family of 6.

    I trust and like my physician. That is worth a lot.

  138. “Based on my experience with a breast cancer diagnosis less than 6 months after a clean mammogram, I respectfully disagree. A doc or nurse who does dozens of breast exams a week might well pick up something that you miss yourself, even if you are very diligent with self-exams, which many women unfortunately are not.”

    This reminds me that I need to make sure DD knows how to do self-exams, and does them regularly. And I agree with Scarlett, especially for younger kids. I’ve read that breast cancer advance very quickly in younger patients, and that’s consistent with what happened with the 2 cousins I lost to it in their 20s.

    Another unpleasant reminder that my kids are growing up. I really miss having toddlers running around the house.

  139. “I’ve been puzzling about what “access” to healthcare really means.”

    I think it means having medical professionals and facilities that are physically accessible within a reasonable distance, that are willing to treat you. The willingness to treat part takes into account the financial aspects.

    Some people on government programs, e.g., medicaid or medicare, live in areas with providers but don’t have access because none of them are taking new patients with those coverages. Others without insurance still have access because of doctors like Rarely Posts’ DH.

    Having medical insurance is no guarantee of access to health care. E.g., as RMS mentioned, some medicare patients can’t find doctors taking any more medicare patients, and locally, some areas have shortages of doctors, especially certain specialties.

  140. “If any med student takes a federally backed loan, or any taxpayer-funded need-based grant, then we the people are supporting their education so the quid pro quo is they have to take all comers as patients without discrimination as to ability to pay or the type of insurance they accept. Forever, I believe.”

    On Halloween night, I was talking about this sort of thing with the MD Dad of one of DD’s besties, at whose house we were having dinner and parents of the friend of his other DD’s friend.

    He mentioned that one of the problems is that PC doesn’t pay very well; even with subsidization of medical education by governments, getting a medical degree is very expensive and time-consuming, and because of that, residency slots in PC specialties go unfilled. We talked about perhaps having less indirect subsidies, e.g., lower levels of subsidizing medical schools, coupled with increased direct subsidies of med students who go into less lucrative specialties like PC, or spend a certain amount of time in underserved areas.

    Within some of the more lucrative, but underserved, specialties, one problem might be MDs who take med school and residency slots, then don’t practice. We know a number of MD moms of our kids’ classmates who fall into this category.

    He also mentioned that in many other countries, medical training takes much less time, with the tradeoff being lower salaries, so it’s very attractive for foreign-trained MDs to try to get the best of both worlds by training outside the US, then moving to the US to practice. Perhaps that model is becoming more common in the US with the increasing presence of PC NPs and PAs.

  141. I hate the notes for OTC meds and I won’t do it. One of the benefits of being a SAHM is the ability to drive to school and administer meds in the parking lot. It is my little personal protest.

    Take a look at this. These two guys – very powerful information. Hard to wrap your head around the idea that so many things we thought were helpful really aren’t that helpful.

    http://www.wfdd.org/story/skip-math-researchers-paint-picture-health-benefits-and-risks

  142. I met a coworker from Canada last month who said he recently had 2 related minor issues from falling. His Canadian doctor would only look at 1 and the second issue required a separate appointment. Seems pretty inefficient to me. Here, if you have multiple issues, the doctor is able to bill more and address them all in one visit.

    Sort of. I did a rotation with a pediatric ortho and she will not see two issues in the same visit, she requires the patient to come back on another day for the second issue. She cannot bill for both issues on the same day. She can bill the extended visit based on time, but the reimbursement is much less that way. If she handles two problems, it takes two full appointments worth of time but she doesn’t get paid for two full appointments.

    When I see patients, I can bill at different levels depending on the complexity (essentially number of issues) that I address. But with my patients, there isn’t much of a time difference in covering two or three issues in one visit, so it’s worth my time to address the additional issue to bill more.

  143. A great cost savings to all would be relaxation of the one year validity of prescriptions or a commonsense decision for docs/PAs to renew some things without a visit – is that national or just MA limitation on validity – many docs won’t renew without an annual visit.

    That’s because they don’t get paid for renewing scripts, they get paid for patient visits.

  144. Mooshi, we had a similar experience when DD was in the hospital for her headaches. The docs refused to do an MRI, they kept insisting there was no reason for it. (They also didn’t do anything else to try to identify a cause of the headaches, they just tried to treat them.) We happened to have a regular eye checkup scheduled for DD the day after she was discharged. The eye doc took one look in her eyes and said “there’s a lot of pressure on her optic nerve, she needs to have an MRI.”

  145. Sorry I couldn’t get to this earlier today…

    The irony in health care/insurance (HC/HI) is that we have far too *much* insurance– and this leads to the vast bulk of our problems in HC/HI. HI is subsidized through the firm (as a non-taxed form of compensation), so the govt encourages us to get far too much insurance (particularly in terms of what’s covered) and it links insurance to a particular job (which causes all sorts of trouble with portability and pre-existing conditions).

    How can we know that we generally have too much insurance (thanks to this regressive and amazingly expensive subsidy)? Consider the role of insurance in every other context– to cover rare, catastrophic losses (as in fire, life, and auto). As a thought experiment, what would auto insurance cover if it resembled HI– and what would that auto insurance cost– and what would it do the related markets (e.g., the cost of oil changes, paperwork, fraud, etc.)?

    The ACA dealt with the govt-created “pre-existing conditions” problem by mandating coverage, spreading those costs to the rest of us. FIne, I guess, as a second-best solution to the problem it unintentionally foisted on us earlier. The ACA also did a nice job by slipping in the “Cadillac Tax”, which was slated to squeeze the subsidy on the upper endincreasingly, lessening the problem above. Unfortunately, the interest groups impacted by the CT are squealing more and more– and may get our feckless politicians to repeal one of the ACA’s more useful provisions.

    Beyond that, the ACA could never be more than a band-aid on a gaping wound. The higher premia were entirely predictable (and have been predicted by me and many others; the ACA simply cannot do much (broad) good without a ton of expense. There are many other secondary and tertiary issues that would help HC and HI (e.g., less regulation on telemedicine, fewer insurance mandates at the state level, fewer restrictions on competition across state lines, more med imports, fewer regs on PA’s and LPN’s, etc.). But the elephant in the room is the subsidy on HI through the firm, which has increasingly jacked up the market for HI– and thus HC– since WWII.

    The long-term answers are either single-payer (with all of its flaws) and wealthy people opting out anyway– or much more of a market-based system with single-payer and charitable care for the indigent. The market is still trying to move us toward true insurance– with much higher deductibles. The ACA’s higher premia and MSA’s/HSA’s have been helpful in encouraging this evolution. It’s always interesting to watch policy, but in this case, it’s really interesting to watch the market try to move toward more efficiency, trying to get around the staggering inefficiencies caused by the govt.

    For those interested, I have two related papers on these topics:
    http://www.realclearmarkets.com/blog/cj31n1-2.pdf
    http://www.independent.org/pdf/tir/tir_18_03_07_schansberg.pdf

  146. Self exams are no longer recommended or taught, AFAIK. They have been shown to be ineffective at detection and reduction of mortality, and yearly doctor exams are thought to be sufficient.

    Saac – I don’t have a study specifically on young men. But there have been some studies that showed that having an annual check up has no effect on long term morbidity or mortality. Statistics look at the efficacy over a large population – it has been received wisdom for a hundred years that the annual check up is a necessary part of health care.

    As for eye exams, every two years is the accepted norm. However, most people go to the optometrist attached to the eyeglass store, not to an ophthamologist as I do every year at my age as recommended. But for many years I went only when I needed to buy new glasses (less often than every two years) for many years when my eyes were stable.

    Recently there has been research that showed that routine prostate screening for men led to worse outcomes because of overtreatment and it is no longer recommended. Similar research results have been found for routine mammograms and outcomes – no statistically significant decrease in mortality, plus many false positives and some unnecessary treatment, but that is not yet widely accepted and recommendations have not changed.

  147. Eric S., I read both your papers. I liked the recognition that quantifying the costs of defensive medicine is very difficult and that reducing obesity does not reduce health care costs. I once read a similar analysis of health care costs for smokers. To me, the problem with your approach is that it assumes too much competence on the part of people needing healthcare. Channeling Rhett, I suspect that the people best able to understand and navigate the health insurance market are not typically the highest consumers of healthcare.

    1% of the population accounts for 30% of healthcare expenditures, from the last estimate I saw, and many of those people are disabled. To me, the reason that a primarily market-based system in healthcare doesn’t work well is that we aren’t willing to let people suffer severe consequences from not purchasing insurance, even when they are capable of rational choice and, more importantly, people who are most in need of care tend to be in the worst position to afford healthcare.

    I suspect these are arguments you’ve heard before. :)

  148. WCe’s besides your very rational arguments against a complete free market, there is also the fact that no country with a successfully operating healthcare system uses a complete free market. So why do we want to be guinea pigs?

    And single payer is not the only other choice. There are many countries that have well functioning healthcare systems based on highly regulated third party payers, probably more countries than single payer countries.

  149. The ACA dealt with the govt-created “pre-existing conditions”

    You’ll have to explain that one.

  150. “Channeling Rhett, I suspect that the people best able to understand and navigate the health insurance market are not typically the highest consumers of healthcare.”

    It’s not just the health insurance market that is a challenge for these patients, but the entire health care system. When even high-functioning totebaggers have difficulty persuading health care providers to order necessary tests or perform indicated procedures, you can bet that the Steven Averys of this world haven’t got a prayer. They don’t do online research, don’t challenge their doctors or nurses, and don’t question anything.

  151. I’m done with my tantrum. I can talk medical errors all day long, but in a context that understands that physicians (and nurses) routinely end their careers, because they have trouble coping with the decisions they’ve made. Sometimes they move on to insurance work, but more alarming they become alcoholics, or kill themselves – at rates much higher than other professionals. We lose the equivalent of two graduating classes of MDs per year to suicide. This is one of the many reasons I will not encourage my children to go into health care.

    When you are a victim of medical malpractice or error, it likely seems that the people involved are indifferent or incompetent. Some of them are. I would love to recount my mistakes (there are many) my lawsuits (a few, all peripheral involvement except that thing that happened when I was about 8 weeks our of school). However, I think most physicians would agree that is that there is little relationship between mistakes and legal actions – which is a shame. We should have systems of making people whole when medical errors cause harm while protecting clinicians and patients from the fallout of the current adversarial environment.

  152. If you don’t feel the need to see an eye doctor every year or two, your prescription is always valid online. I but incredibly cheap prescriptions glasses ($25 or so) because I am prone to leaving them everywhere. You enter your prescription – there is no “expiration date”.

    For yearly renewals of medications (like the pill) – I agree that they should be available “behind the counter” (a little stricter than OTC, but does not require an Rx). I also sympathize with the plight of prescribers. You assume liability for the writing of the prescription. It also takes a few minutes to do per patient. If a doc has a panel of 2500 patients and 1% per week are asking for uncompensated services (doctor’s note, rx refill, question about symptoms), a significant amount of time is spent that doesn’t generate revenue. At least in an HMO model, there is much less concern about these types of encouters – providers pay is separated from encounters (to a large degree).

    This is the biggest stumbling block in most systems to being able to email your provider with a question about a recent medication, or have a “phone visit” or telemedicine encounter. Most insurance won’t reimburse for those events. HMOs and other capitated care solves this (though certainly opens up its own problems.)

  153. I’d need to look back at what I wrote, but I would guess that I was saying that obesity and smoking are secondary and/or indirect. Clearly, the direct costs of both are huge, but we have a system that subsidizes and encourages both. I also like to observe that you can have whatever system you want, but if people are determined to live unhealthy lives (esp. assuming we’re going to subsidize them), the outcomes cannot possibly be pretty. So, we need to be careful not to compare to utopia here. (Related to that, to MM’s point, there are all sorts of HC/HI systems in the world, none of which are fully satisfying.)

    Low-info is a common problem in markets. Very few of us know much of anything– from how a PC works to whether the dude in the fast food restaurant spit on your burger. Health care probably has more of that, but putting third-parties in charge of payments exacerbates that problem by changing incentives. When people are footing more of the bill, they’re inclined to try to get educated. Are there various folks who are not capable of that. Sure. Again, a common problem. And what to do with them will depend on one’s comfort with policy paternalism.

    On The ACA dealt with the govt-created “pre-existing conditions”. The ACA covers PEC. The govt created a lot of the PEC problem, by making insurance much, much more expensive, through the subsidy and mandates (making it less likely that people will get insurance of any type) and by connecting it to the firm (if I have cancer, it will be difficult to change jobs because the new insurance company, rightly, views this as asking them to provide fire insurance while my house is on fire).

  154. I’ve heard the argument (but never examined it) that smoking saves the system money. It kills off people (sometimes quite suddenly, smoking is most likely to kill you via a heart attack) often in their prime. This saves the system a lot of money is social security, disability, care for chronic conditions, etc.

  155. (if I have cancer, it will be difficult to change jobs because the new insurance company, rightly, views this as asking them to provide fire insurance while my house is on fire).

    That’s not true at all. That’s not how group policies work.

  156. I am happy to overpay for medicine. I am also happy to over pay for national defense. I think the benefits of this overpayment circulate the globe.

  157. It’s how small group policies work (or did in 2010). Husband changed jobs to a startup. Child had a hip problem from birth. Despite our continuous insurance, we couldn’t make any claims regarding it for the first six months we were insured that year.

    Also, if there had been any gap in insurance, care for pregnancy and birth could be declined. This happened in 2011 with a large employer. We eventually provided evidence of continuous coverage, and was covered. However, if we had let things slip, we could have been out 10-20k. As far as I understand, the ACA has changed both of these things.

  158. Well, of course, we’re footing the bill either way. But people (and esp. politicians) often like the costs to be subtle…

    That’s part of why MSA’s are useful part of second-best or third-best solution, if we’re going to continue limping away from so much govt intervention toward a much freer market, with its benefits (except for the indigent).

  159. There was an interesting story on the local news last night about prescriptions costs. In the examples they showed it was often cheaper to pay cash for your prescription then to have the prescription run through your insurance. Apparently the pharmacy can’t tell you it is cheaper due to the contracts they sign with insurers, so it is up the consumer to research and ask questions before filling a prescription.

  160. they’re inclined to try to get educated.

    In the past you’ve railed against Social Security. All you plans seem to hinge on the average person having a near limitless font of excess cognitive ability and executive function with which to navigate all this. The reality is there just isn’t.

  161. DH, who studies such things, says bluntly that a heart attack is a good cheap death, compared to many of the other options. Smokers may “save” Social Security from having to make some payments, but they also drive up costs for Medicare and Medicaid. Ironically, one could argue that Totebag habits may be costly for society, as people with healthy lifestyles avoid heart disease or lung cancer, living long enough to be diagnosed with dementia.

  162. I’ve railed against SS for its nasty tax on the working poor and middle class (thousands of dollars per year, even at the poverty line) and its anemic ROI (0% on average; negative for African-Americans). Aside from its usefulness as a way for politicians to score cheap political points in a low-info political environment, who could possibly be a fan of the status quo?

    To your point and the prospects for various levels of paternalism, a number of countries mandate retirement savings into 401k’ish accounts and then tie the hands of “investors” to varying degrees. If we’re paternalistic on this topic, we can still make them save and then prevent them from putting it into wild investments.

    Pensions and pay-as-you-go have obvious limitations. The private sector has moved from defined benefits to defined contribution. Hopefully, SS will transition into something similar.

  163. who could possibly be a fan of the status quo?

    Everyone who notices how much of a disaster the 401k system has been for the vast majority of people.

  164. “On The ACA dealt with the govt-created “pre-existing conditions”. The ACA covers PEC. The govt created a lot of the PEC problem, by making insurance much, much more expensive, through the subsidy and mandates”
    Eric, you smoking dope or what? You make no sense whatsoever. The preexisting condition crisis was a gigantic crisis years and years before the ACA. That is the reason that states tried high risk pools, which were a singular fail. They did not work at all for the obvious reason that if you corral all the super expensive people into one insurance pool, it is going to be insanely expensive to cover them.

    Before the ACA, my kid was facing a lifetime of uninsurability. This was the reality for all pediatric cancer survivors. Many of those families ran out of coverage due to insurance lifetime max caps, another horrible practice that was disallowed under the ACA. The terrible problems for people with pre-existing conditions, and people who had exceeded their lifetime caps, was a big incentive for pushing for the ACA. I do not know of anyone in the pediatric cancer community who wants to go back to pre-ACA days.

  165. High risk pools didn’t work because states/the federal government weren’t willing to subsidize them enough. I think high risk pools (or secondary insurance from the federal government when costs exceed the actuarially expected amount by a particular factor, paid for by general tax revenues) are a good balance between private and single payer insurance.

    Of course, I come from the mindset that the necessary trade-offs between cost and service is usually achieved with some level of competition. I’m open to being convinced that healthcare is a natural monopoly, like gas, water, sewer and electricity.

  166. A natural monopoly requires huge overhead costs (as with utilities)– and thus, that production of the good or service is most efficient when provided by a single producer. (From there, the govt typically regulates those prices, hopefully doing the best they can to simulate competitive prices after they’ve allowed efficient production.)

    As such, neither HC nor HI is a natural monopoly in any economic terms– outside of, perhaps, a few narrow areas, such as R&D for RX’s, niche-level treatments. (Remember too that we’re talking about various markets within HC– from cancer treatments and births to allergy shots and broken bones.)

    Of course, the govt can set up as the HC and HI industries with even more monopoly power than it has already granted it– directly and esp. indirectly. (The ACA increased monopoly power further, as we’ve seen– and will continue to see– with more market concentration.) Then, we’d deal with the net inefficiencies and equities/inequities of that system.

  167. MM, the govt interventions in HI go back 70 years– far before the ACA– causing a.) insurance prices to be much much higher (except for the indigent, everyone would have cheap, long-term HI if it only covered catastrophic and preventative care); and b.) trouble with “portability” (where your insurance is connected to your firm, creating more trouble with PEC’s when people try to switch jobs and thus insurance). That’s not the entire problem with PEC’s, but those two causes have made the PEC problem far worse.

  168. everyone would have cheap, long-term HI if it only covered catastrophic and preventative care)

    If that were true and we were spending far less, wouldn’t it stand to reason that with vastly less of a market, the incentive to develop new treatments would be vastly lower and the care available today would be significantly inferior to what’s currently available?

  169. Eric, in your model, where would coverage for ongoing expensive issues like uncontrolled asthma, Parkinson’s and ALS fit? Is that catastrophic or covered by individual?

  170. If a doc has a panel of 2500 patients and 1% per week are asking for uncompensated services (doctor’s note, rx refill, question about symptoms), a significant amount of time is spent that doesn’t generate revenue.

    This is starting to change. Medicare now allows us to bill for “Chronic Care Management.” We need to track the time we spend on the non-visit stuff and when we hit 20 minutes in a month for a patient, medicare will pay us $42. It’s recognition of all the time we spend on those things that aren’t billable.

  171. Rhett, if one joins a group plan, then yes, mostly. (Even there, firms will find those workers unattractive and will avoid them if possible. We see a lot of efforts along those lines, in the last decade or so.) But “companies with group plans” large enough to avoid trouble narrows the employment field somewhat.

    Rhett, there would be somewhat less of a market for non-catastrophic care, since we’d foot the bill instead of foisting it onto third-party payers– and thus, others through generally higher premia. There would somewhat more of a market for catastrophic care, since more people would be insured in that realm. Quantitatively, I don’t think the effects would be large, either way.

    WCE, it would come down to the expense of the treatment. Insurance usually covers relatively rare, “catastrophic” (i.e., very expensive) events. So, Parkinsons and ALS fit. If UA is really expensive, then it would fit too.

  172. Eric, I was thinking of the hospital bills associated with uncontrolled asthma. As medical care has improved, more people live a long time with chronic conditions, with premature infants a prime example, which is why the catastrophic model doesn’t work very well. Most people can’t afford the ~$5-10k out of pocket family maximum but also can’t/don’t budget for insurance with a sufficiently low deductible to meet their paycheck-to-paycheck lives. It will be interesting to see how much uncompensated care decreases under the ACA.

  173. There would somewhat more of a market for catastrophic care, since more people would be insured in that realm. Quantitatively, I don’t think the effects would be large, either way.

    Come on, Eric. You claim that if your path had been followed 70 years ago “everyone would have cheap, long-term HI if it only covered catastrophic and preventative.” Cheap meaning we’re spending half as much on health care? You shrink the industry by 50% and you “don’t think the effects would be large” on innovation, R&D, etc?

  174. WCE, we don’t know how that sort of thing would pan out, at least quantitatively (and to your point, whether that would be easier under the status quo). Perhaps it would be analogous to long-term nursing-home care insurance.

    Rhett, we’re not sure how much spending would decrease. HC is definitely a “normal good” and as income/wealth increase, we would expect people to spend more on HC, so a lot of the growth in spending is not at all surprising (and is independent of our dog’s breakfast approach to markets and govt in this realm). And a lot of current spending is wasted, given the overly-extensive role for insurance, defensive medicine, etc. So, I grant that there would be some changes (perhaps significant), but it’s not clear how much they would be. To your point, there might be less R&D on certain things, but at present that level of R&D is being subsidized– i.e., taken from some people to finance (inefficient) R&D. Perhaps that’s a net gain…

  175. we’re not sure how much spending would decrease.

    You said, “everyone would have cheap, long-term HI if it only covered catastrophic and preventative care”.

  176. Saac – “morbidity” in mortality and morbidity refers to serious disease. Most of the longitudinal studies are looking for that as well as death statistics. My point is that the current received wisdom frequency for periodic adult visits without illness do not appear to result in a statistically significant reduction in adverse outcomes, and in fact medical practice and my discussion with my doctor reflect these long term studies and changing recommendations. However, the consumption and cost of preventive health care and prescription renewals and pharmacy services are based on practices from ten years ago, state regulations, insurance reimbursement guidelines, govt mandates for no cost services, etc that may not reflect the latest and most cost effective thinking.

  177. Rhett, I agree that medical R&D would be less but people paying for care might be more likely to comply with the complicated protocols around exercise and appointments that make medical care effective. One of the challenges of providing prenatal care to a high risk population is that mothers can’t/don’t comply with recommendations to stop drinking/smoking/using illegal drugs, they have no backup support for foster care if they are hospitalized with complications, they often lack transportation and they can’t/don’t comply with dietary and monitoring for issues like gestational diabetes. Stem cell transplant patient protocol is even more complicated.

    I think there is more to be gained in health outcomes from improving patient compliance and helping patients make trade-offs appropriate to their lives (vs. one size fits all, complex, unrealistic medical recommendations) than in any other area.

  178. but people paying for care might be more likely to comply with the complicated protocols around exercise and appointments that make medical care effective.

    That assumes the existence of some great untapped font of executive function. I’m not convinced it exists. The fact that even in matters of life and death treatment compliance is poor seems to support the idea that the great untapped font of executive function simply doesn’t exist.

  179. Rhett, but the bar for defining “compliance” is set way too high. Instead of a reasonable recommendation for two drinks or fewer/week, we have agencies recommending that women of childbearing age not drink at all, IN CASE they get pregnant. My kids don’t count as “exclusively breastfed” because I used some formula while my milk was coming in. The AAP no longer considers my infants in danger because they often slept in my bed, like infants all over the world for millenia.

    I think 80% of the population makes choices mostly appropriate for their situations and it’s the recommendations/protocols that won’t consider cost/risk/benefit that drive statistical noncompliance.

  180. Rhett, but the bar for defining “compliance” is set way too high.

    I was thinking more about diabetics managing their blood sugar.

  181. It appears that the International Diabetes Foundation has considered the problem of resources and how guidelines developed for high resource countries (U.S., western Europe) may not be appropriate for low resource countries.

    In another couple decades, we should know how much “optimal” diabetes control affects health/life outcomes. At what level of blood sugar control does “something else” become the dominant variable affecting health? I always think of the observation that Seventh Day Adventists (strict diets, no alcohol, strict moral rules, mostly vegetarian) live ~3 years longer, on average, than typical Americans.

  182. I always think of the observation that Seventh Day Adventists (strict diets, no alcohol, strict moral rules, mostly vegetarian) live ~3 years longer, on average, than typical Americans.

    Makes me think of:

    You can live to be a hundred if you give up all the things that make you want to live to be a hundred.
    – Woody Allen

    It’s even worse that it’s only three extra years.

  183. “everyone would have cheap, long-term HI if it only covered catastrophic and preventative care”

    I tend to agree. I am encouraged by the trend to high deductible plans accompanied by HSA. I think these plans address some of WCE’s questions and obviate the need to differentiate between catastrophic and chronic, but expensive, conditions. HSAs in combination with payroll deduction plans help address the problems of those with low executive function.

    Relatively healthy families that typically don’t hit the deductible can usually operate on a cash basis, relieving everyone of the costs associated with claims for those services, thus reducing the overall cost of delivering the same amount of services.

  184. “Most people can’t afford the ~$5-10k out of pocket family maximum ”

    I’m skeptical of this. E.g., a family that can continually have two cars that are each less than 5YO could probably afford that sort of out of pocket by prioritizing health care more highly relative to its other spending.

    But IMO it should be their call as to where health care falls among their spending priorities.

  185. “healthcare is a natural monopoly, like gas, water, sewer and electricity”

    Haven’t we had discussions here about choosing electricity providers? Houston, was it you who posted about some of your experience in choosing a provider of electricity?

    We chose from among a large number of providers when we decided to install PV.

  186. Maybe I’m missing part of the argument, Finn. Even people with high-deductible insurance are filing claims for every visit – that is how they are getting negotiated rates, and accumulating ‘credit’ towards their deductible.

    If we magically replaced all non-indigent patients’ insurance with high deductible plans, do you expect there to be less care provided? Exactly which care would not be provided? (less MRIs, less ER visits, less medication prescribed?) If less care is not provided, there must be another way that the system is saving money – which parts would be eliminated? Are there support staff, insurance administrators, physicians that are no longer required and would lose their jobs?

    I don’t mean to be confrontational, but I do not see how HD plans save lots of money, except through people avoiding care. Studies show that they do not rationally avoid care (necessary care is missed, unnecessary care is still done). Also, with a HD plan, families with two ill members would spend 10k a year, every year on medical expenses, above copays and insurance costs. That is a huge burden to a median-income family.

  187. Finn, OK, maybe electrical distribution is a natural monopoly. And at least in my state, I know the regulator works hard (because she’s my friend) to protect people from fluctuating natural gas prices by allowing utilities to raise capital more easily when natural gas rates are low and limiting nonessential capital investments (safety/environmental compliance would be exceptions) when natural gas rates are extremely high.

    I’ve thought of my social group of friends and none of them have two less-than-five year old vehicles in their families. Most of them are college educated and some have graduate degrees, so it seems safe to assume that the 2/3 of Americans without college degrees are also unlikely to have two less-than-five-year-old vehicles. Median household income in the U.S. is $52k, so $5-$10k is 10-20% of a year’s pretax income.

  188. If I were to try to affect health costs without affecting quality, I would expedite drug approvals based on global use. I think the FDA is overly risk averse and unwilling to look at global information in its cost/risk/benefit analyses.

    This contrasts with my view of the legal system, where I think the Supreme Court’s use of global standards is inappropriate if their role is to determine whether laws are “Constitutional”.

  189. I don’t mean to be confrontational, but I do not see how HD plans save lots of money, except through people avoiding care. Studies show that they do not rationally avoid care (necessary care is missed, unnecessary care is still done). Also, with a HD plan, families with two ill members would spend 10k a year, every year on medical expenses, above copays and insurance costs. That is a huge burden to a median-income family.

    Copay count against the deductible and out of pocket max. We save quite a bit without high deductible plan. We always reach the out-of-pocket Max and the premiums are much cheaper so our total out-of-pocket cost is less with a high deductible plan then the other options.

  190. Thanks Meme. I’m still glad for the annual spots with my young man, perhaps because we are at various docs for various parts of him fairly often, I think, compared to other kids, so it’s nice to step back occasionally and look at the whole of at least all the pieces together. I am not a fan of the way people are split into so many pieces for medical specialties to consider. I understand the complexities of each, but think there is more cross-influence of various body systems than say, electrical and plumbing systems in a building.

  191. It’s been a while, but back in my single days I had something like a $few hundred deductible, and often didn’t hit it, so those years I didn’t file any claims. I also filed my own claims back then, so I was on a cash basis with my providers.

    Nowadays it seems like most of the doctors, besides the urgent care clinics, take care of the insurance claim filing on behalf of their patients.

    Perhaps I’m being naive, but I’m thinking that if I had a HD plan and told my PCP’s staff about it, I could just pay cash (or with a CC) after each office visit. They know I have a PPO plan (I don’t think they’d have taken me as a patient without insurance), so as a member of that PPO they’re obligated to charge me the PPO rates, but I don’t see why they couldn’t just forgo the claim filing until I let them know that I’d hit the deductible, which in many years wouldn’t happen.

    If a lot of other folks similarly don’t hit their deductible every year (and the deductible level should, IMO, be set at level such that that is the case) and would be on a cash basis with their providers those years, freeing the providers from filing and tracking claims, wouldn’t that reduce the overall cost of delivering the same level of care?

  192. Ada, again perhaps I’m naive, but I don’t see why a provider would need to file claims to get the negotiated rate. E.g., if the provider knows the patient is a member of a PPO, can’t they just charge the negotiated rate on a cash basis?

  193. “If we magically replaced all non-indigent patients’ insurance with high deductible plans, do you expect there to be less care provided?”

    Perhaps. If the cost is more transparent, perhaps some parents will be less likely to demand antibiotics for every cold or suspected ear infection. And perhaps urgent care clinics will get some of the visits that might otherwise have been ER visits (oops, sorry Ada, less work for you).

    “Exactly which care would not be provided? (less MRIs, less ER visits, less medication prescribed?) ”

    My guess is that some people will consider a bit more before availing themselves of care, and would be more likely to consider the costs (e.g., urgent care vs ER).

    Some people might also be more likely to see a PA or NP for conditions that don’t seem serious enough to warrant an MD visit.

    And yes, fewer MRIs; my guess is that some people who would demand an MRI now would be less likely to do so if they are paying for it on a cash basis.

    “If less care is not provided, there must be another way that the system is saving money – which parts would be eliminated? Are there support staff, insurance administrators, physicians that are no longer required and would lose their jobs?”

    I think there would be fewer jobs for support staff that file claims on behalf of patients, insurance staff that processes claims, and thus also for insurance administrators and HR.

    There might be fewer ER jobs, and some other services (e.g. MRI) might be less used. However, with some services, I can see where the cost per use might go up, as the fixed costs associated with those capabilities might need to be spread over a smaller number of events.

    I don’t know that physicians would lose jobs, given that there seems to be a shortage. But there might be more jobs for PAs and NPs.

  194. BTW Ada, I really appreciate your participation in this discussion. Your perspective is quite enlightening, especially as DS has not yet completely ruled out a career in medicine.

  195. Finn, I often think that the medical assistant who takes your weight/blood pressure could be replaced by a machine.

  196. Finn, there is nothing stopping the office from charging you whatever they want on a cash basis. But if they, or you, don’t file a claim, it will not be applied to your deductible. And the insurance company has to verify the visit is for something they cover, because it won’t apply to your deductible if it isn’t (such as cosmetic procedures). And every urgent care I’ve been to has billed the insurer directly.

    Some people might also be more likely to see a PA or NP for conditions that don’t seem serious enough to warrant an MD visit.

    Patient’s often don’t have a choice – it’s see the NP/PA now, or wait days/weeks/months to see the MD. A lot of urgent cares only have NPs or PAs.

    Finn, I often think that the medical assistant who takes your weight/blood pressure could be replaced by a machine.

    WCE, most of MAs do a hell of a lot more than just take weights and BPs. They call back patients, call other providers to exchange information, they help the providers manage their loads, handle a lot of administrative stuff, etc. If I had to do everything my MA does for me, I’d have time to see about three patients a day.

  197. They call back patients.

    I have a really hard time seeing how this is efficient. My experience has been.

    1) call doctor’s office with a question
    2) wait a day, then get a call back from the doctor’s office in which, either
    a) the MA repeats the doctor’s answer, I ask a followup question, which must be asked to the doctor and the MA call back the next day; or
    b) I don’t grab the phone quickly enough, the MA doesn’t leave a message, I call back the doctor’s office and wait for a call back the next day

    I’ve found it simply, easier, cheaper, and less time consuming to just schedule an appointment

  198. Denver, I understand that medical assistants are useful, but the more you substitute machines for people, the fewer medical assistants you should need to complete the tasks that machines can’t do.

  199. “But if they, or you, don’t file a claim, it will not be applied to your deductible. ”

    This goes back a while, so it may be dated, but back when I had a plan with a deductible, I wouldn’t file any claims until I hit the deductible, at which point I’d file claims for everything for that year, and I’d get reimbursed for what went above the deductible threshold.

    In many years, I didn’t hit the deductible threshold, and thus didn’t file any claims.

  200. Finn – I don’t have the executive function/organizational capabilities to keep track of all my medical expenses for the year and the file the claims en masse when they reached a certain threshold. Perhaps I’d be less sloppy if I really needed the money. However, the few times I’ve tried to use a FSA for healthcare, I lose money because I forget to save receipts. That doesn’t seem like a realistic way to navigate the system for most people.

    Also, I’m with DD – it is hard to see all the things that an MA does. I’m going to do a pelvic – I need all the supplies there, with labels, with appropriate culture swabs. I need the results to get sent to lab with the appropriate requisition. While robots move drugs around in big hospitals, they don’t move supplies. Also, I need to get ahold of a patient that need a change in therapy vs an overhead on an X-ray – the MA looks it up in the chart and get the person on the phone. In the ER we mostly use techs (similar to MAs) – they are crucial in keeping rooms cleaned (new sheets between every patient), stocked, doing EKGs, getting the right sized crutches, applying splints, bringing popsicles to the kid that needs to prove he won’t vomit anymore, etc. I can do almost everything they can (I don’t know how to do an EKG and I don’t know par levels for stocking) and nurses can definitely do everything a tech can – but the tech is the cheapest cog in the medical wheel.

    Also, NPs are only marginally cheaper than MDs. For most things, they bill at 85% the MD rate. Some studies indicate they over-refer (which is my experience), which may negate their savings.

  201. Cordelia, if the doc was calling you back, it would be the same phone tag (although easier to ask follow up questions) and it’s much more cost-effective for an MA to play phone tag with you than for the doc. I do frequently call family members directly and give them my cell number to call me back, because it does greatly simplify the phone tag, and I know most of the discussions will be fairly in-depth. Plus I’m not actually in the office so my MA can’t tell a caller to hand on while she gets me on the phone.

    WCE, doing vitals is such a small part of the MA’s job. And I don’t see how it would be much more efficient to have a machine. Someone would still need to bring the patients to the machine and show them how to use it.

    Ada, I like to think I don’t over-refer. I tend to be judicious because, for a lot of my patients, it’s a pretty big project for family to get them out to an appointment. On the other hand, because I am mobile, I can’t do a lot of the procedures and test things that can be done in a regular office. So I do need to refer patients to dermatology for simple skin lesions that could be removed in an office and things like that. And I do make a lot of referrals to home health providers for PT/OT, wound care, etc.

  202. Denver Dad, I was thinking of the MA’s who do vitals at ~10 minute intervals for prenatal patients. Most of us could run a blood pressure/weight machine without instruction and weigh about a pound more than we did the week before.

  203. Ada, I was thinking that if you had a HSA and paid for services directly from that (e.g., with a Visa card connected to the HSA), you could look at your account at any time to see how much you’d spent for the year, and how much of it went toward your deductible (although that would require someone to categorize spending between what does and doesn’t go toward the deductible). If the HSA could upload receipts that would obviate the need to save receipts.

  204. Finn, our HSA card somehow knows which things can be charged to it, presumably because they are coded somehow in the pharmacy’s system. So prescriptions get paid for, but Sudafed doesn’t, and I have to whip out a separate card.

  205. WCE, the weight/BP machines at the grocery store seem simple, but I wonder how that would work in practice. At one doc’s office, where we are supposed to check a box if our address/pharmacy have changed, people often don’t. I don’t see how the address matters, but the wrong pharmacy could create havoc. If people don’t do that faithfully, how much staff time would be taken up correcting errors? Just look at the “self checkout” line; how many people go through without help vs. how many need assistance from the worker stationed right there?

    If we are going for straight efficiency, check-ups could use the system of an ob/gyno clinic for low income women I’ve seen where women are called back in groups. I think there are 6 vitals stations and about 3 techs that move from one to the next. Then someone with a bit more expertise comes around and holds the normal interviews. If that raises any flags, the woman goes to an exam room where an MD eventually comes in and does a routine test. It is not convenient (or reassuring, if you’re not used to it) to be in the herd, but man, is it efficient! My guess is that very few people who are accustomed to more personal attention would stay in this system if paying more would get them more private, traditional appointments.

  206. Rocky, that’s pretty slick. Also in the “gee whiz, the things chips can do these days” category are the paper cups at WDW. A chip on the bottom tells the soda machine how many refills are left on the cup, and the time remaining to complete them. I also like the bracelets at the waterpark that you hold in front of a panel to have your locker pop open, no key required.

  207. At one of my ob-gyn offices, they put the scale in the bathroom so you can close the door, weigh yourself, and report the results. Presumably some people lie, but on the other hand, you’re not being weighed in the hallway like a side of beef as everyone walks by.

  208. Rocky, and your kid can’t try to blackmail you later with info they got looking over your shoulder!

  209. WCE, again, that is not the only thing those MAs are doing. And I would not trust patients to self report the results. Also, I’m a summing the machines would not be out in the open in the waiting room, so yo still need someone to call the patients back.

  210. Denver Dad, I’m not suggesting that MAs only do those things. I do think, though, that putting the scale in a more secluded location and maybe transmitting the number straight to some computer somewhere would be a lot less embarrassing.

    I had three ob-gyns in Denver who were so bizarre I simply stopped going to ob-gyns. Two of the women (at different practices!) were clearly eating-disordered; they weren’t normally thin, they were freakishly thin, and they yelled at me about my weight with an astonishing furor. Remember, I’m still under the 29 BMI mark, and my regular NP just says, “Yeah, you should lose some weight. Moving on.” The third one was an elderly guy with lots of pictures of his 40-years-younger blonde trophy wife and blonde trophy kids interspersed with creepy fertility statuettes. After talking to him, I was unconvinced that he’d paid any attention to his CMEs since about 1965.

    So if I ever actually need a gynecologist, I may be emailing you for recommendations.

  211. RMS, is there still a way to pay for the Sudafed with your HSA, or get reimbursed from your HSA for it?

    My guess is that your drugstore has two merchant codes, one for its pharmacy, and one for the rest of it, and only the pharmacy part isn’t blocked. But there’s a lot of stuff, like contact lens solutions (and probably Sudafed), that the IRS considers to be medical but would be blocked if my guess is correct.

  212. Finn, there are two different kinds of medical-ish money accounts. One is an FSA (Flexible Spending Account) and one is an HSA (Health Savings Account). They cover different things. You can buy OTC stuff with FSA money, but only some OTC stuff with HSA money. I think you have some significant confusions about how these high-deductible, HSA-linked insurance programs work, based on several of your posts over the last few days. See:

    http://www.slu.edu/Documents/hr/benefits/HSA%20Reform%20Flier%20OTC%20Meds.pdf

    If I bothered to hassle my NP for a script for Sudafed, I could get the HSA to pay for it, but it’s more trouble than it’s worth. Although then I wouldn’t be subject to the purchasing limits…hm.

  213. It sounds like I underestimate the complexity of people/machine interactions in healthcare. Denver Dad’s comment makes me pleased that my nurse practitioner just asked me my weight when her MA was busy and took my word for it. Much of her patient population has social issues; I only have medical issues and so I’m comparatively easy.

    RMS, your gyn’s sound awful. Most GYN’s are female here, and some of them are plump.

  214. RMS, I’m not very knowledgeable about HSA and high deductible plans because neither my employer nor my wife’s gives us that option, so we haven’t invested much time in learning the details.

    I know enough to know that if it were an option, I would definitely investigate.

  215. Denver Dad, I’m not suggesting that MAs only do those things. I do think, though, that putting the scale in a more secluded location and maybe transmitting the number straight to some computer somewhere would be a lot less embarrassing.

    Rocky, I agree. I’m more concerned about the BP, because 1. the machines are notorious for being inaccurate, and 2. especially in the case of pregnancy, a high BP can be an indication to do a lot of further testing, and I can easily see where someone could be inclined to “fudge” when they tell the MA/nurse/MD what it is because they feel fine and don’t want to deal with the extra stuff.

  216. Also, I work in an area where we are inherently distrustful of patients being compliant, so that’s where I am coming from. I have patients who self-administer their meds, and with some of them, I have zero confidence that they are actually taking them as they are supposed to. But the patient and/or family refuses to pay the fee to have the facility administer them. I have one patient who insists on checking her own blood sugars, and I’m sure she is not reporting them accurately because she doesn’t like taking pills. (I do check her A1C regularly.)

  217. Finn – In order to open an HSA, you have to be enrolled in a high deductible plan. Your employer likely does not offer one of those, since when it does the employer sets up HSAs. If your plan does qualify for an HSA, you can set up your own online or at the bank or brokerage house. I had one when I was on the MA exchange. Eligibility stops when you go on medicare. I let it accumulate over the five years (no use or lose) and now can use the balance to pay my medicare premiums with pretax dollars. If you or your employer make contributions to a regular use or lose FSA, you or your employer can’t also contribute to an HSA in the same year. If your FSA is limited, vision or dental only, there are different rules.

  218. Rocky, have you gotten caught by the limits? I like to have decongestant stashed in several different locations, so I sometimes run out in several places and wind up purchasing more for each one in a short span of time, usually not all at the same place, because I don’t think of all of them at once. Anyways, I have wondered sometimes if I’ll be snagged for having just bought 30 tabs in the last week and trying to buy one more. So far, I haven’t been.

  219. This Sudafed discussion is reminding me that we need to buy the real stuff on our next out of state trip, since we can’t buy it in-state anymore without a prescription. And that when I was in the hospital with the twins for a month, I did Sudoku and my specialist and I joked that patients who did mAth were OK.

  220. Yeah, I run out, because DH (and when he’s here, DSS) use the stuff in my stash and never replace it. Grr.

  221. Our last major resupply was when my family was getting together around Christmas and I told everyone I wanted real Sudafed for my gift that year. Fortunately, it doesn’t go bad.

  222. In order to open an HSA, you have to be enrolled in a high deductible plan. Your employer likely does not offer one of those, since when it does the employer sets up HSAs

    Not always. DW’s insurance is HSA compliant but the employer does not do HSAs, they specifically tell employees that they need to set them up on their own.

    I have been stopped from buying sudafed because I tried to buy too much at one time. I like the 12 or 24 hour pills, and DW likes the short acting ones, and I like to buy the big boxes because they are cheaper. So I was trying to buy a big box of each at the same time and they wouldn’t let me do it.

  223. Fortunately, it doesn’t go bad.

    You can take most pills well beyond their expiration dates without any issues.

  224. If your FSA is limited, vision or dental only, there are different rules.

    Then you can also have an HSA. We did that this year because we knew DS would be getting braces.

  225. “We did that this year because we knew DS would be getting braces.”

    The HSA annual contribution limit was well below the cost of braces, so I asked the orthodontist’s office if they’d be willing to split the cost over two years, and they agreed. We paid half on year, late in the year (Nov or Dec) and started then, and paid the rest the next Jan, and thus were able to get it covered.

  226. Finn, how much do braces cost there? Even going back to 2005, the HSA limit was over $5,000 for a family. DS’ braces were about $4,500 this year. (That’s the full cost – insurance knocked a chunk off, then our orthodontist gives a 5% discount for paying cash up front, and another 5% off for agreeing to do all the follow up appts between 9 and 2. We paid around $2,300 out of pocket.)

    Or are you talking about an FSA?

  227. Tote baggers can’t keep up their sudaphed stash, and aren’t sure if they have an FSA or an HSA and we hope that the solution to health care is for people to bear more responsibility for navigating the system?

    DD – I’m sure you don’t over-refer, just as I never under-refer. It’s all those other terrible medical practitioners that we are talking about.

    Finn – we left our employer-funded HSA option in 2011 (prior to the ACA). I couldn’t keep track of how much we had spent. It was all through an internal company site, and DH had access and I didn’t (he was the subscriber). I was making the appointments and trying to decide if we should get the expensive radiology study in December or January, but couldn’t figure it out, so switched to the HMO. I post this, not to highlight my lack of organization, but to mention that there were significant barriers to tracking and managing spending – and I think I am above-average in raw capabilities to do that kind of thing.

  228. Medically knowledgeable people – is the CA-125 as a screening tool for ovarian cancer something that is a reasonably reliable tool, or is it one of those things that is may cause undue worry? A grandmother died of it at age 42, and I have 1-2 of the very vague, subjective symptoms that could be caused by a dozen other things. A prior Gyn had ordered it before, but current doctor does not, and I don’t know whether to request it.

  229. Oops, as I’ve mentioned earlier, DW and I have never had HSA as an option.

    I got quotes from 3 orthodontists, all were over $5k even after the discount for paying up front.

    Our dental insurance is very basic and doesn’t cover orthodontia.

  230. Ada, I have had similar issues with a spouse who has access to the medical insurance website but is not gifted at managing those details.

    When just as many men complain that their wives are oblivious to life’s minutiae as women complain that their husbands are oblivious to life’s minutiae, I may be obliged to accept the principle of gender equality. (I am neither completely joking nor completely not joking.)

  231. WCE, it’s a chicken/egg issue. Are men (as a generalization) oblivious to the minutiae because they are incapable or handling it, or are they oblivious because their wives want to be in charge of the household? Of course the answer depends on your experiences, and what I’ve seen is that (again as a generalization) women prefer to be “in charge” of running the household and handling all of this stuff. Obviously it varies on an individual basis.

    I handle all of this stuff and DW doesn’t have a clue, but that’s by choice. She’s capable of handling it but is much happier not dealing with it, whereas I’m a control freak and want to know what is going on with everything, so this works well for us. However, I’ve found we’re in the minority among the people we know.

  232. Anon, I’ve never heard of that so I can’t help. Women’s health is not my area at all.

  233. Denver Dad, I kind of see your point, because it is consistent with the observation that single men do less housework than single women. I have no interest in home decor, and when Mr WCE asked why I didn’t decorate, I said I would be fine with whatever he liked. If we ever sell our house, we should probably get it staged, because neither of us has talent in that area.

    Given that Mr WCE has ~6 months of mail piled up and failed to pay bills occasionally prior to marriage because he forgot, I prefer to view paperwork minutiae as “a game of chicken I’m not willing to lose.”

  234. Anon — Although I’ve had the CA 125 test, my understanding is the same as explained by the Mayo Clinic I linked below. I have a family history of ovarian cancer. My doc did the test because I suggested it, but explained that it’s not an accurate predictor. That’s also what other family members have told me. From what I remember, the vague early symptoms of ovarian cancer are the primary reason to do testing, so you may be in that category. But I don’t know and maybe others with more expertise or experience will sound in.

    http://www.mayoclinic.org/tests-procedures/ca-125-test/basics/why-its-done/prc-20009524

    If you have a strong family history of ovarian cancer or you have the BRCA1 or BRCA2 gene mutation, your doctor may recommend a CA 125 test as one way to screen for ovarian cancer.

    Some doctors may recommend CA 125 testing combined with transvaginal ultrasound every six months for women at very high risk.

    However, some women with ovarian cancer may not have an increased CA 125 level. And no evidence shows that screening women with CA 125 decreases the chance of dying of ovarian cancer. An elevated level of CA 125 could prompt your doctor to put you through unnecessary and possibly harmful tests.

    I agree that managing all HI/HC issues can be challenging even for totebagger types. I sorta dread this time of year when I have to make decisions on health insurance because 1) i hate to review all the material and 2) I’m always left vaguely unsure I made the right decision.

  235. Nothing to do with health insurance, but everything to do with the overall topic of how much insurance to carry. One of my high bandwidth kids who is solid middle class but far from UMC for her zipcode found out what it means to have bare bones car insurance, ie no collision or rental car coverage. The other driver presented his version of the story (euphemism) so it was he said she said, so she ended up responsible for her repairs (not his). Plus the elderly cat is in need of very expensive late life maintenance. And there was a leak in the apartment, not all of which damage was covered by the condo assoc or her own bare bones homeowner’s insurance. And she splurged earlier this year on a sister bonding vacation, so the cash was depleted. Lower premiums were a reasonable middle class tradeoff, but things can snowball early. Medical costs much faster. I believe that the cost effective body shop and vet are cash only – no credit cards.

  236. Plus the elderly cat is in need of very expensive late life maintenance.

    I say this as a life-long per owner. That’s when you put the cat to sleep.

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