Redstate health care debate.

Inspired by story nyceve wrote, I put together a couple of diaries about what Pacificare was trying to do to 17-year-old Nick Colombo, which was to deny a potentially life-saving cancer treatment. I wrote one about Pacificare's Chief Medical Officer, Dr. Sam Ho and used parts of a previous diary about Cigna's CMO, Dr. Jeffery Kang, then a short one announcing that Pacificare had caved. I posted both of these are Redstate.com because I saw it as a bipartisan issue. I was posting the telephone numbers to Pacificare everywhere I could think of, and figured I would try Redstate.com. It generated some interesting discussion over there, and quickly turned into a debate on a single-payer system. I wouldn't say I really changed any of their minds, but I at least got a couple of them to start asking the right questions. If anyone wants to see the diaries and commentary, see my newly opened Redstate page: http://www.redstate.com/blogs/dopeman

And you think this wouldn't happen in single-payer.... by St. Louis Conservative ....healthcare? Do you think the government in Britain doesn't deny services because they don't have enough resources? In fact, it's far worse under a government system, because it is 100% under control of the state. The patient has no recourse. At least under a private system, there are other providers to go to. In a single-payer system, the state has a monopoly, and you have abide by whatever decision the health bureaucrats make for you. You, the patient, and your doctor really have no control over your health treatment. It's all in the hands of faceless, uncaring, unfeeling government bureaucrats. Anytime the beneficiary of the service is separated from the entity that actually pays for the service, you are going to have problems. That exists in our private, insurance driven system today, but it is still worlds better than a socialistic system in which government has complete control over everyone. “.....women and minorities hardest hit”

Thank you for beating me to this reply StL Con by simpson316 Well said. Fighting for conservatism one day at a time.

Certainly there will be by Dopeman denials once the single payer model is in place, but they will based on better reasons than profit. Sometimes every treatment isn't viable or medically necessary (even though a dying patient or dying patient's family may think it is). The difference is that it will be the patient's treating doctors who will give the yea or nay. Doctors who are most loyal to their patients, not their stockholders. I urge you to read my other story here, about Dr. Kang and Dr. Ho, Chief Medical Officers for Cigna and Pacificare respectively. Compare the Medicare process with the private managed care model. My facility takes both. A Medicare patient comes in, is assessed, and the course of treatment ordered by a physician is started immediately. Periodically, Medicare audits our charts. If everything isn't kosher (if every admission and treatment reviewed was not determined to be medically necessary) the facility gets in trouble. If there is a pattern of this, the facility gets in BIG trouble. Following are the basic steps: Payment is denied for services or days deemed to be not medically necessary. Fines can be imposed as well. The facility is flagged and audit frequency is increased. If more problems are found, audit frequency (or percentage of charts audited) is increased. This continues incrementally up to 100% auditing. If there are enough problems, Medicare will shut you down. Actually all they do is eliminate their contract with the facility, in the current private managed care world that is death because ALL of the private insurance companies will follow suit. Either way, it's death by attrition. One key difference is that if my hospital makes the mistake and admits a Medicare patient who doesn't meet criteria and Medicare denys the claim (after the fact - treatment rendered), the patient doesn't start getting calls from our collection department. If the same thing happens with a private insurer after the fact - treatment rendered - and yes, this does happen even with "pre-authorization" which is really only authorization to begin care pending review and NOT a guarantee to pay, the mistake of the insurance company AND the facility result in a big, fat unexpected bill for care which the facility AND the insurance company told the patient was covered. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton

Who decides what is "medically necessary"? by St. Louis Conservative What if I have an aching knee and I want knee surgery? To me, that is medically necessary. So you want government bureaucrats deciding what is and what is not medically necessary? That's a scary, SCARY world you paint, pal. Second, who will "decide" what a procedure is worth? Will some government health bureaucrat arbitrarily decide how much an open-heart surgery is worth? How do you do that in absence of a market? I guarantee you that a health care provider/doctor and the government will have disagreements over how much a procedure is worth. What if a doctor doesn't want to perform a procedure for an arbitrarily decided price that he deems is too low? Will the government force him to do it? Will the government force him to retire from his practice? I thought liberals believed in freedom and liberty. “.....women and minorities hardest hit”

Your doctor decides. by Dopeman Not A doctor, YOUR doctor. YOUR doctor, the one who has examined your knee in person. The one who looked you in the eye, shook your hand and told you he could fix it. The doctor whose primary responsibility is your knee, not next quarter's projections. The problem is bureaucracy. The cost absorbed by the system (and in the case of single-payer, the taxpayer) for all the things that can increase cost - including frivolous lawsuits and and fraud - will be FAR outweighed by the elimination of bureaucracy. Did you catch that? More bureaucracy in the private sector than the public sector. FAR more. The problem is pre-authorization and concurrent review. THAT is what makes your health care expensive. You would be amazed to know the number of man-hours that go into the pre-auth and concurrent review process. We're not talking cheap labor either, these are well-paid, skilled, licensed employees who are tied up for hours. And hours. Wasting our time. Spinning our wheels. A pre-auth means one nurse (me) providing clinical data to a nurse at the insurance company (who has never seen the patient) to justify the care. Calls, voicemails, faxes... it can take hours. So at the end of the process the reviewer might authorize two days. This, when we BOTH know full well that this is a course of treatment that takes 5-7 days. So after the two days, another process is initiated to justify continued care. This next step is FAR more in depth, because every treatment or medication rendered, every test ordered has to be justified by the hospital nurse to the insurance company nurse. Keep in mind - BOTH nurses know it will take at least 5 days. So after this, the reviewer might authorize one more day, and the process will be repeated every day for the remaining 3-4 days until the patient is discharged. All of this is utterly, utterly useless. It is a wasteful burearocratic dance that you pay for. I thought conservatives believed in cutting bureaucracy to save money. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton A five -day stay by Dopeman where I work is about $4000. If you count the manhours in pre-authorization and concurrent review that I and other nurses spend (including the nurses at the insurance company), you are probably looking at about 1/4 of that cost. Not to mention, when the review escalates to a doctor-to-doctor review (our doc justifying the care to their doc) and you calculate in the cost of THEIR time... wow. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton

I take issue..with the 'your doctor' part... by jdub19 I just had a procedure, disc removal in my neck. It was the most painful 7 months of my life. My doctor wanted to due a procedure that was appoved by the FDA last July...all in all, a better option than spinal fusion. The 'nurse' that looked at the pre cert cancelled my surgery less than 24 hours before...no reason given. That sent my surgeon and his team into a frenzy to re submit for another procedure, just so I could get relief. All in all, the new procedure would have been better now, and in the future... What is your answer to the joke that is pre- cert? " Got to love the Lord for making things like that." Morally Compromised

I am one of those, what you by Dopeman I am one of those, what you called a 'pre-cert' nurse. What happened was not that nurses decison, it was the ins. company. Nurses don't make those decisions. That nurses only role was to communicate your clinical information to the ins. co. My guess is that nurse fought tooth and nail to get you that procedure, but lost. Some times we lose. In the end they have to power to say no. The hardest part of my job is turning patients away. It happens every day - I know they need the care, my doctor (their doctor) has ordered it, but the insurance company said they won't pay. I do it every day. The answer to the joke that is pre-cert is to eliminate it, and the bureaucracy that goes with it (including my job). I described the Medicare model in a comment above. No pre-cert. No surprise bill if care is denied after the fact. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton

Why is this so? by KyleH Why is all this bureaucracy is place if it is just wasting money? You would think that a private profit-making insurance company would see a great opportunity here: chop out all this waste, charge half of what the other companies do, and still make a bundle of profit (and please their patients). What is keeping insurance companies from doing this?

Overall it's a cost by Dopeman savings to them. If the treatment is denied, they don't have to pay for it. If they deny after the fact, after the treatment is rendered, the patient ends up getting hit with the cost, so they don't have to pay for it. If the patient dies while waiting for a major pre-approval [see Nataline Sarkisyan] (one so large that the hospital isn't willing to risk absorbing the cost by going ahead with the treatment), they don't have to pay for that either. This system works for them, it just doesn't work for you. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton

NEW! Not going to profit by KyleH But the wasted money is not going into profit, it is paying for the red tape. You yourself said that they are paying nurses to fill out a bunch of forms. They are paying for extra managers and secretaries to push paperwork. This isn't profit. At the very least, even if what you say is true, why go to a government paid system? Why not just pass a law that says that insurance companies have to pay for everything the primary care physician orders? Why not go for the simplest solution? If the problem is non-coverage, how does a government system solve it in a way that a private system could not?

Yes, the red tape is expensive. by Dopeman Just like frivolous lawsuits are expensive (although far less so than the red tape), so just as with law suits, the cost of avoiding them is weighed against the cost of anticipated court settlements. It's not that ALL of the money saved in denials goes to profit, just the money from denials less the bureaucracy costs (and in some cases, court settlements). That formula must have proven to be more profitable than eliminating the bureaucracy and not denying care. Remember, care is very expensive (even when you consider the bureaucracy that would be eliminated on the provider's end). It's a very complicated formula that works mostly for stockholders, not patients. Health care, like fire or police services shouldn't be profit-based. If your house is on fire or somebody is shooting at it, there are fire and police services to save you. It should be the same if you are going to die and there is a medical treatment available that can save you. "There comes a time when a rat's gotta ask himself: what's in it for the rat?" - Templeton

NEW! Ok, dope, replace "a" with "your" in my post. by St. Louis Conservative You didn't answer a single point I put forward. The bottom line ...[sorry, I kinda stopped reading at "Ok, dope"]

:::: Posting my opinions on this issue there made me think of Obama's famous speech at the 2004 convention: "We worship an awesome God in the blue states, and we don't like federal agents poking around in our libraries in the red states..." I used this theme of Obama's to appeal to them in one of my opening posts:

I posted this in a few other locations, and decided to stop and sign up here. I wanted to get those telephone numbers out and I think this is a story (and calling those numbers a form of activism) that can be appreciated by anyone along the political spectrum. Obviously there is a left slant to my writing and opinions, that's who I am, but there are conservatives who will be outraged at the death of somebody's child in the name of cost containment. There are conservatives who will be critical of the priorities of these doctors.

I thought I would be immediately banned when it became clear where I sit politically, but I wasn't. I was careful not to flame (or respond when flamed), but instead just kept overwhelming them with nuts and bolts facts and undeniable logic. Obviously I wouldn't try to post a Bush bashing diary over there, but whenever I write something that I think could have bipartisan appeal, I will cross-post there. Arguing with them (and mostly winning) was interesting. [orig. posted at dkos 4/2/08] (type-o's and minor corrections made from original commentary, and emphases added).