Fixing healthcare...government vs free market (long)

sklarbodds

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Nov 30, 2006
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TLDR; The real issue in healthcare is cost of service...neither party has offered a plan to fix that or honestly even started talking about it. There isn't a silver bullet answer, even though both parties think there is.


My background
I spent the better part of a decade designing enterprise IT solutions for a very large health insurance company (role: enterprise architect). A large portion of that was understanding everything about how the insurance business works. I worked frequently with the claims departments, actuarial professionals, plan design teams, even marketing. I have a pretty solid understanding of the health insurance world.

I am not a doctor, nor do I understand completely how the financials and business side of running a hospital or medical system, but there are some things I can conclude based on my previous work.


The Affordable Care Act
The ACA was both good and bad (or maybe...ineffective) in a lot of ways. Honestly, the biggest problem by far is it's name. It does very little to address healthcare costs and in some cases drove costs higher. It would have been better named "The Health Insurance Quality and Access Act". But what it did do well in a few categories:
1) It improved access to health insurance for those who can't afford it by way of subsidies to help with premiums and reduced out of pocket costs (handled separately, but the poorest could effectively get a zero cost plan).
2) It improved the "minimum standards" plans had to meet (this could be good or bad, because it drove up costs some).
- Certain care had to be covered
- Kids could stay on their parents plan until 26
3) It minimized the amount of profit a health insurance company could make <--- Americans were misled how big of a problem this actually was
- The main catalyst here was something called Medical Loss Ratio. Oversimplified it was basically a rule that said if a health insurance company paid less than $.85 in claims per $1.00 it collected in premiums, it must refund that money. The remaining $.15 had to pay all of the insurance company's bills/salaries/advertising/etc. It essentially made all insurance companies non-profit (many already were tho)
4) It set standards for access to care (some of which was redundant to current laws in some states, but it made it more universal) for each plan
5) It required providers to meet certain electronic medical records requirements

So here's where it failed:
1) COST. Washington thought that insurance companies were just gouging people (I'm not saying it never happened, but very very few were) but they completely failed to look at what providers were charging for services.
2) The "co-op" plans that it funded was a complete failure. Turns out it's actually kind of hard to create an insurance company that doesn't just hemorrhage money. Not to mention the oversight was minimal at best and these co-ops kept going back to the government for money and nobody really asked why.
3) It added complexity and coverage to plans (not necessarily wrong by itself) but it failed to address any ways of monitoring those costs
4) CMS (who essentially became the defacto overseer of all things ACA) let people absolutely abuse the system.
- We had to take whoever they said was eligible. They would have people sign up in June for the previous January (if you know anything about managing risk, this is a huge no-no).
- They allowed people to essentially not pay Nov and Dec premiums...still have coverage...and then re-sign up in January with no penalty and no way of collecting Nov and Dec premiums
5) Obviously the technical rollout was an unmitigated disaster.
6) This is not really the ACA's fault, but the provisions in the bill to help insurance companies offset greater risk was essentially defunded later (risk corridors thanks in large part to Rubio). 3 R's...Risk Adjustment, Risk Corridors and Reinsurance...were a big part of how the insurance companies could take the additional risk. This was put in so that the health insurance companies could price their plans affordably knowing the government would help them recover costs in the back end...Well Rubio got people to believe these were "insurance company bailouts" which is a joke because the plan costs were reduced counting on those subsidies. It's literally money that went straight to the people.


Many insurance companies ended up just getting out of the individual market because it became such a money pit.




So what about the cost of care
OK, so we got all the ACA background out of the way. Now where do we go next.

When talking about cost, it's one of those topics that's crazy hard to even really pinpoint. My favorite example is a shoulder x-ray. I was helping work on a cost comparison mobile app and one of my favorite things to do was put in a shoulder x-ray as an example and see the varying levels of cost around the metro. It ranged from $30 at a small clinic all the way up to $1,500 at a local hospital. The reason I felt that was such a great example was it highlights how crazy costs can be all over the map. I promise you, that x-ray from the hospital is not 50x better than the one at the clinic. But the hospital probably does more of them than the small clinic.

When you start to see things like that, you realize that the system is rigged against the consumer.

So how did we get here? Simple...the consumer was taken out of the price equation when employee health benefits became standard. When the consumer no longer cares/knows what the price of the service is (because insurance companies paid for it...and the consumer didn't even pay the premiums or for the service). Back then you could visit your doctor (or the doctor would come to you) for a few bucks. Obviously medical care has gotten better and technology is expensive, but it'd be hard to argue it's not completely out of control.

Then you add in the way pharma is run...basically you made it so that bringing a drug to market is ABSURDLY expensive (close to $3B)...so of course pharma companies are going to try to make absurd profits on drugs that make it to market so they can cover any potential loses from those that don't (and because...you know...money).



The Government Option
I want to be perfectly clear, I'm not 100% sold on either option to fix this....

How it would work:
Obviously this would be single payer (Medicare for all, etc). The way it would drive down costs is quite simply the same way Medicare does...it just tells hospitals and doctors you have to take X amount for this service. I don't care what your costs are, too bad. In some areas where retirees are more common, this causes providers to charge more to non-Medicare patients to make up losses on some services in Medicare.

Basically, it's the mob boss version of controlling costs. If the government was the only one paying claims they can set the prices of the services. Can't make your business work on those prices? Too bad. You need $100 for a shoulder x-ray because you invested in new equipment? Here's $50.

The good about this option:
1) It's quick and decisive.
2) It would force providers to quickly adapt to cheaper ways of doing things or close

The bad about this option:
1) Bluntly...tons of hospitals built on big budgets would have to close. That might seem like a good thing (and maybe for the long run it really is)...but lack access to care literally costs lives. If hospitals around the country close you end up with long waiting lists (like some parts of Canada) and people that have to drive hundreds of miles to see a doctor.
2) Government does kinda suck at running "businesses". Medicare still has millions in waste every year, VA hospital systems kinda blow, and see #2 in "the bad about the ACA. I don't know how you can be intellectually honest and say dumb stuff like "Well other countries do it" and not understand the complexities of the American healthcare system. Geographic issues are just the tip of the iceberg here. I'm not saying it can't be done...but people who just float it like it's no big deal "because other countries can do it" really get under my skin.
3) Obviously "Death Panels" is just a political scare term to try to make people frightened of this option, but liberals who want this should at least acknowledge that coverage decisions by the government, even if they're prudent, will result in people complaining the government is letting them die. It's at the very least an optics problem that has to be addressed somehow.


The Free Market Option
I am very much a free market capitalist, but again I want to be perfectly clear, I'm not 100% sold on either option to fix this....

How it would work:
Well, simply put...you enable the consumer to make their own health financial decisions. Basically you somehow teach them to go to the $30 clinic for their shoulder x-ray instead of the hospital...forcing the hospital to adapt.

This is really freaking hard (I'm going to make it sound simple, but it's not)...but I do have a plan that I *think* could work here....hear me out.

1) Require providers to give FINAL costs before performing services.

2) Encourage medical plans to use Health Savings Accounts (through incentive or mandate, I don't care). Setup rules that basically say, "If you don't use the money in your HSA, you can keep it tax free". This actually gives you a great path to fund care for poor people too by allowing the government to help fund their HSA...but the same rules apply, if you don't use the money, you keep it.

Let's say that I have my HSA plan and I have a $5k deductible (which is low compared to ACA plans right now, I get that). If I am a low income person and the government funded my $5k and at the end of the year if I don't use it it's paid out to me....well you're damn right I'm going to shop around if the hospital tells me I need a $1500 shoulder x-ray.

3) Use technology to help consumers shop for care, compare costs, compare quality. Again, this is actually absurdly hard, but it's the only way to give the power back to the consumer.

4) Make generics available sooner on Rx...(but you'd probably also have to reduce the cost of going to market).


The good about this option:
1) The consumer is finally aware of the cost of their choices and directly affected.
2) Providers would have to start really competing against each other on cost...right now they compete SOLELY on value. When's the last time you heard a hospital advertise cheap care?
3) When it comes to "cost to the taxpayer" this one is probably a lot less.
4) It would probably phase out poorly priced systems more slowly (could be done with government, but this would be more natural)


The bad about this option:
1) It's really hard to make consumers aware of healthcare choices and cost, especially when time is a factor. REALLY hard.
2) Right now just about every provider is 'procedure based' billing. Essentially..."I perform this action and bill you this much". Ideally, you would want more "condition based" billing. I have joint damage in my shoulder...providers find a more affordable way of treating me. There are 1000s of medical codes they bill for and bluntly, it's not reasonable for a consumer to understand all of them enough to make an informed decision.
3) Right now, providers are not at all setup to tell you costs before receiving the service. This is not an easy change, but an essential one.
4) This would require a certain amount of uniformity that just doesn't exist anywhere in the medical field. Even EMRs (Emergency Medical Records) have 100s of different formats. Transferring medical records is actually a HUGE business because all these systems don't really talk to each other in a universal format.



Bottom Line
-----------------
Again, the real issue with American healthcare is cost of service. Ironically if you fix that, it becomes WAY cheaper to help people who can't afford it. Access isn't as big of an issue. People won't go broke getting sick...etc. etc.

But our current hospital system is not built for affordability. Luxury hospitals are everywhere now. No matter how we fix it, the American people would have to learn to expect a more "thrifty" version of care....at least as a base expectation. Note, I'm not saying lesser quality of care...I'm saying lesser luxury of care.

Until we fix the money problem, all other solutions are just putting band-aids on a massive wound that will eventually code out.
 

H2Oman

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Jun 29, 2001
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Damn, you are on a roll today! This is also good stuff. But I have to say, “other countries can do it.” Don’t bant me, only kidding.

it is about cost for sure. Here is my knowledge of the subject matter. I sue insurance companies and enjoy it a lot. One of the issues that typically leads to lawsuits from injured people is how much of the special damages will an auto carrier pay? The insurance industry will tell me that the MRI that was billed at $1500 only costs $500 on average throughout the US. And that’s all it will pay. I have never lost on this issue. The injured is awarded damages at $1500. Often I will agree that the bill is outrageous but that’s not my client’s fault. They are referred for an MRI to a certain place and have no control over the treatment or the cost. You have explored this issue Nicely, I just wanted to add in this dimension. This would support a govt controlled program.

On the other hand, the client is required to pay back insurance providers who funded care necessary to make the client well from the accident. Paying back Medicare is a bitch. I have a hard time wanting the govt to be in control of anything similar.

Just some thoughts on the subject from my industry.
 
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Red_Hack

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Dec 20, 2005
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Our system is all for profit, at any cost. No part of it is built for the welfare of the patients. It places a permanent penalty on people born with genetic or DNA weakness and forces them to pay for the rest of their lives for something they had no control over. And milks those people for every penny they make.

In essence, they are made a slave to the medical system. A life sentence. Without guilt. Without being asked.

Free Market capitalism, requires removing humanity or morals to maximize profits.
The Medical field is the study of humanity with morality.

But if we learned anything in 2020, it is that almost half of Americans do not care about other Americans. At all.
 

Frostradamus

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Dec 2, 2014
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What other industry gets to have secret pricing arrangements and don't have to tell their consumer customers the cost of their products and services? Abolish "in-network" and "out-of-network" pricing schemes and permit people to purchase insurance across state lines. Mandate providers advertise pricing online and force them to compete in a manner that is visible to the public. Health insurance shouldn't be the primary mechanism to cover medical expenses. It should be a safety net utilized only for severe emergency trauma or treating diseases like cancer. Generally speaking, a trip to the doctor should cost $50-$100 for 90% of visits. It's the 10% insurance should cover.
 

sklarbodds

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Nov 30, 2006
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What other industry gets to have secret pricing arrangements and don't have to tell their consumer customers the cost of their products and services? Abolish "in-network" and "out-of-network" pricing schemes and permit people to purchase insurance across state lines. Mandate providers advertise pricing online and force them to compete in a manner that is visible to the public. Health insurance shouldn't be the primary mechanism to cover medical expenses. It should be a safety net utilized only for severe emergency trauma or treating diseases like cancer. Generally speaking, a trip to the doctor should cost $50-$100 for 90% of visits. It's the 10% insurance should cover.
I agree 100% with everything you said except the state lines thing. I don't care if they did, but that will not affect pricing.

But yes.... many families spend more money in healthcare than they do for their house, yet they have no idea what the cost of that thing will be before they buy it. Insane.
 

Trike Rider

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Jan 6, 2009
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TLDR; The real issue in healthcare is cost of service...neither party has offered a plan to fix that or honestly even started talking about it. There isn't a silver bullet answer, even though both parties think there is.


My background
I spent the better part of a decade designing enterprise IT solutions for a very large health insurance company (role: enterprise architect). A large portion of that was understanding everything about how the insurance business works. I worked frequently with the claims departments, actuarial professionals, plan design teams, even marketing. I have a pretty solid understanding of the health insurance world.

I am not a doctor, nor do I understand completely how the financials and business side of running a hospital or medical system, but there are some things I can conclude based on my previous work.


The Affordable Care Act
The ACA was both good and bad (or maybe...ineffective) in a lot of ways. Honestly, the biggest problem by far is it's name. It does very little to address healthcare costs and in some cases drove costs higher. It would have been better named "The Health Insurance Quality and Access Act". But what it did do well in a few categories:
1) It improved access to health insurance for those who can't afford it by way of subsidies to help with premiums and reduced out of pocket costs (handled separately, but the poorest could effectively get a zero cost plan).
2) It improved the "minimum standards" plans had to meet (this could be good or bad, because it drove up costs some).
- Certain care had to be covered
- Kids could stay on their parents plan until 26
3) It minimized the amount of profit a health insurance company could make <--- Americans were misled how big of a problem this actually was
- The main catalyst here was something called Medical Loss Ratio. Oversimplified it was basically a rule that said if a health insurance company paid less than $.85 in claims per $1.00 it collected in premiums, it must refund that money. The remaining $.15 had to pay all of the insurance company's bills/salaries/advertising/etc. It essentially made all insurance companies non-profit (many already were tho)
4) It set standards for access to care (some of which was redundant to current laws in some states, but it made it more universal) for each plan
5) It required providers to meet certain electronic medical records requirements

So here's where it failed:
1) COST. Washington thought that insurance companies were just gouging people (I'm not saying it never happened, but very very few were) but they completely failed to look at what providers were charging for services.
2) The "co-op" plans that it funded was a complete failure. Turns out it's actually kind of hard to create an insurance company that doesn't just hemorrhage money. Not to mention the oversight was minimal at best and these co-ops kept going back to the government for money and nobody really asked why.
3) It added complexity and coverage to plans (not necessarily wrong by itself) but it failed to address any ways of monitoring those costs
4) CMS (who essentially became the defacto overseer of all things ACA) let people absolutely abuse the system.
- We had to take whoever they said was eligible. They would have people sign up in June for the previous January (if you know anything about managing risk, this is a huge no-no).
- They allowed people to essentially not pay Nov and Dec premiums...still have coverage...and then re-sign up in January with no penalty and no way of collecting Nov and Dec premiums
5) Obviously the technical rollout was an unmitigated disaster.
6) This is not really the ACA's fault, but the provisions in the bill to help insurance companies offset greater risk was essentially defunded later (risk corridors thanks in large part to Rubio). 3 R's...Risk Adjustment, Risk Corridors and Reinsurance...were a big part of how the insurance companies could take the additional risk. This was put in so that the health insurance companies could price their plans affordably knowing the government would help them recover costs in the back end...Well Rubio got people to believe these were "insurance company bailouts" which is a joke because the plan costs were reduced counting on those subsidies. It's literally money that went straight to the people.


Many insurance companies ended up just getting out of the individual market because it became such a money pit.




So what about the cost of care
OK, so we got all the ACA background out of the way. Now where do we go next.

When talking about cost, it's one of those topics that's crazy hard to even really pinpoint. My favorite example is a shoulder x-ray. I was helping work on a cost comparison mobile app and one of my favorite things to do was put in a shoulder x-ray as an example and see the varying levels of cost around the metro. It ranged from $30 at a small clinic all the way up to $1,500 at a local hospital. The reason I felt that was such a great example was it highlights how crazy costs can be all over the map. I promise you, that x-ray from the hospital is not 50x better than the one at the clinic. But the hospital probably does more of them than the small clinic.

When you start to see things like that, you realize that the system is rigged against the consumer.

So how did we get here? Simple...the consumer was taken out of the price equation when employee health benefits became standard. When the consumer no longer cares/knows what the price of the service is (because insurance companies paid for it...and the consumer didn't even pay the premiums or for the service). Back then you could visit your doctor (or the doctor would come to you) for a few bucks. Obviously medical care has gotten better and technology is expensive, but it'd be hard to argue it's not completely out of control.

Then you add in the way pharma is run...basically you made it so that bringing a drug to market is ABSURDLY expensive (close to $3B)...so of course pharma companies are going to try to make absurd profits on drugs that make it to market so they can cover any potential loses from those that don't (and because...you know...money).



The Government Option
I want to be perfectly clear, I'm not 100% sold on either option to fix this....

How it would work:
Obviously this would be single payer (Medicare for all, etc). The way it would drive down costs is quite simply the same way Medicare does...it just tells hospitals and doctors you have to take X amount for this service. I don't care what your costs are, too bad. In some areas where retirees are more common, this causes providers to charge more to non-Medicare patients to make up losses on some services in Medicare.

Basically, it's the mob boss version of controlling costs. If the government was the only one paying claims they can set the prices of the services. Can't make your business work on those prices? Too bad. You need $100 for a shoulder x-ray because you invested in new equipment? Here's $50.

The good about this option:
1) It's quick and decisive.
2) It would force providers to quickly adapt to cheaper ways of doing things or close

The bad about this option:
1) Bluntly...tons of hospitals built on big budgets would have to close. That might seem like a good thing (and maybe for the long run it really is)...but lack access to care literally costs lives. If hospitals around the country close you end up with long waiting lists (like some parts of Canada) and people that have to drive hundreds of miles to see a doctor.
2) Government does kinda suck at running "businesses". Medicare still has millions in waste every year, VA hospital systems kinda blow, and see #2 in "the bad about the ACA. I don't know how you can be intellectually honest and say dumb stuff like "Well other countries do it" and not understand the complexities of the American healthcare system. Geographic issues are just the tip of the iceberg here. I'm not saying it can't be done...but people who just float it like it's no big deal "because other countries can do it" really get under my skin.
3) Obviously "Death Panels" is just a political scare term to try to make people frightened of this option, but liberals who want this should at least acknowledge that coverage decisions by the government, even if they're prudent, will result in people complaining the government is letting them die. It's at the very least an optics problem that has to be addressed somehow.


The Free Market Option
I am very much a free market capitalist, but again I want to be perfectly clear, I'm not 100% sold on either option to fix this....

How it would work:
Well, simply put...you enable the consumer to make their own health financial decisions. Basically you somehow teach them to go to the $30 clinic for their shoulder x-ray instead of the hospital...forcing the hospital to adapt.

This is really freaking hard (I'm going to make it sound simple, but it's not)...but I do have a plan that I *think* could work here....hear me out.

1) Require providers to give FINAL costs before performing services.

2) Encourage medical plans to use Health Savings Accounts (through incentive or mandate, I don't care). Setup rules that basically say, "If you don't use the money in your HSA, you can keep it tax free". This actually gives you a great path to fund care for poor people too by allowing the government to help fund their HSA...but the same rules apply, if you don't use the money, you keep it.

Let's say that I have my HSA plan and I have a $5k deductible (which is low compared to ACA plans right now, I get that). If I am a low income person and the government funded my $5k and at the end of the year if I don't use it it's paid out to me....well you're damn right I'm going to shop around if the hospital tells me I need a $1500 shoulder x-ray.

3) Use technology to help consumers shop for care, compare costs, compare quality. Again, this is actually absurdly hard, but it's the only way to give the power back to the consumer.

4) Make generics available sooner on Rx...(but you'd probably also have to reduce the cost of going to market).


The good about this option:
1) The consumer is finally aware of the cost of their choices and directly affected.
2) Providers would have to start really competing against each other on cost...right now they compete SOLELY on value. When's the last time you heard a hospital advertise cheap care?
3) When it comes to "cost to the taxpayer" this one is probably a lot less.
4) It would probably phase out poorly priced systems more slowly (could be done with government, but this would be more natural)


The bad about this option:
1) It's really hard to make consumers aware of healthcare choices and cost, especially when time is a factor. REALLY hard.
2) Right now just about every provider is 'procedure based' billing. Essentially..."I perform this action and bill you this much". Ideally, you would want more "condition based" billing. I have joint damage in my shoulder...providers find a more affordable way of treating me. There are 1000s of medical codes they bill for and bluntly, it's not reasonable for a consumer to understand all of them enough to make an informed decision.
3) Right now, providers are not at all setup to tell you costs before receiving the service. This is not an easy change, but an essential one.
4) This would require a certain amount of uniformity that just doesn't exist anywhere in the medical field. Even EMRs (Emergency Medical Records) have 100s of different formats. Transferring medical records is actually a HUGE business because all these systems don't really talk to each other in a universal format.



Bottom Line
-----------------
Again, the real issue with American healthcare is cost of service. Ironically if you fix that, it becomes WAY cheaper to help people who can't afford it. Access isn't as big of an issue. People won't go broke getting sick...etc. etc.

But our current hospital system is not built for affordability. Luxury hospitals are everywhere now. No matter how we fix it, the American people would have to learn to expect a more "thrifty" version of care....at least as a base expectation. Note, I'm not saying lesser quality of care...I'm saying lesser luxury of care.

Until we fix the money problem, all other solutions are just putting band-aids on a massive wound that will eventually code out.
Keep it simple. Remove protectionism in the drug industry. Also Incentivize people to take their meds on a regular basis through cheaper premiums. This keeps people from having heart attacks, strokes, etc that cost a large amount of money to the system. This will also keep people out of nursing homes and from using all their assets before turning over to Medicaid. Nursing home costs is the biggest expense for Medicaid.
 

sklarbodds

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Remove protectionism in the drug industry.
Can you tell me what you mean by that? Is it preventing them from being sued due to side effects? It seems like there's lawsuits against drug companies all the time...in fact, allowing them to be sued would probably lead to higher drug costs, would it not?
Also Incentivize people to take their meds on a regular basis through cheaper premiums.
I agree that if you can get people to take their medications more diligently, that would have a really big positive effect on the health of the nation as a whole, but how would you do this in practice? How would you prove that an average 70 year old is in fact taking their medication and not just dropping a pill in the toilet every day?
This keeps people from having heart attacks, strokes, etc that cost a large amount of money to the system. This will also keep people out of nursing homes and from using all their assets before turning over to Medicaid. Nursing home costs is the biggest expense for Medicaid.
So if I understand you correctly, you're advocating for lower usage through preventative health measures = lower cost for everyone? Do you really think that would be enough to radically effect the system?
 

lolwat

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Sep 8, 2016
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I appreciate the large write up. I think a lot of this comes down to we have to have a blend. The private industry is already built.. lets put some rules and guard rails around it. I don't think cutting over to a 'public option' is like flipping a switch. Bernie and the bro's did their best to try to sell it like that. It feels like if it were an IT project... both political parties are a lot like the vendor trying to sell you a solution (free market or public), how its so easy, it can be "life and shift" in 3 days to the public option, have 70% ROI and there is every reason to use their product. Then an EA swoops in like, well it would take about 3 months to get it shifted, its not that easy, and your ROI isn't there because 2/3rd of the features won't work within our processes, so it will take 18-36 months for all the processes to align and/or development effort to even attempt to measure anything related to ROI.

But depending on government to break it down like..

Requirements may include utilizing existing infrastructure - hospitals, insurance companies, etc.

Features - affordable care and quality care baseline. maintain choice. allow people to pay more if they can afford it for anything highly specialized.

Affordable and quality - there have to be easily established and agreed upon standard ways to treat certain health issues. My L4 disc is herniated and degrading. They need a MRI to see what's going on to make an informed medical decision as doctors. They know they need X resolution to do the job right. They know those machines cost Y. Instead of ranging from $700 to $3300 to get a MRI is swimtown, perhaps the rule is set to cap what they can bill at $1100. I don't need to subsidize the brand new state of the art machine that needs the highest of resolutions for brain surgery to know I have a herniated disc.

yadda yadda..

Insert special interest groups worried about their slice of the pie, how its easy to toss terms around "death panels" and "bail out" to kill it politically because R's and D's are too loyal to the team sport and less the results, and that it would probably take 6-10 years in absolute best case scenarios to put something in place to make a difference.. I fear it has to fail in epic proportions before we can really address it. The political climate has doomed any effort to fix it to fail from the beginning in my opinion. And to be honest.. i dont care if its a liberal idea or a conservative one, perhaps a blend.. i don't care.. i just wish they would address it. Give Donald credit for it or Joe Biden, or whoever the next one is.. i really dont care.
 

sklarbodds

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It feels like if it were an IT project... both political parties are a lot like the vendor trying to sell you a solution (free market or public), how its so easy, it can be "life and shift" in 3 days to the public option, have 70% ROI and there is every reason to use their product. Then an EA swoops in like, well it would take about 3 months to get it shifted, its not that easy, and your ROI isn't there because 2/3rd of the features won't work within our processes, so it will take 18-36 months for all the processes to align and/or development effort to even attempt to measure anything related to ROI.
Lol that analogy hit really close to home with me haha! Spot on.
 
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Trike Rider

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Can you tell me what you mean by that? Is it preventing them from being sued due to side effects? It seems like there's lawsuits against drug companies all the time...in fact, allowing them to be sued would probably lead to higher drug costs, would it not?

I agree that if you can get people to take their medications more diligently, that would have a really big positive effect on the health of the nation as a whole, but how would you do this in practice? How would you prove that an average 70 year old is in fact taking their medication and not just dropping a pill in the toilet every day?

So if I understand you correctly, you're advocating for lower usage through preventative health measures = lower cost for everyone? Do you really think that would be enough to radically effect the system?
Yes the PBMs and CMS are already tracking prescription compliance numbers but they are implementing it incorrectly. Pharmacies get hit with lower reimbursement rates and higher DIR fees if their patients have a low compliance rating. We need to put the accountability in the hands of the individual rather then the pharmacy.

I mean removing protectionism in the the sense that a hospital can buy insulin for 5$ and a pharmacy will pay 200$ for the same drug. The pharmacy turns around and submits 400$ to insurance and will get paid 190$-350$ depending on their drug pricing contract, insurance company billed, DIR star rating etc.