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July 31, 2007

15 Years

After relating yet one more insane go-around with our country's health care system, Kevin Drum snarks, "But did you know that in France they're so impoverished that they only have one MRI machine for the whole country? And the waiting list is 15 years? And nobody knows how to operate it anyway because the instructions are in English and no one in France speaks English?"

July 31, 2007 | Permalink

Comments

Rather than wait three (3!) days (days!) for approval he forked over nearly $2,500? That's "insane" all right.

Posted by: ostap | Jul 31, 2007 2:26:02 PM

Sorta on topic: Rudy's 'Single-payer is European... Socialist... not American' bullshit on healthcare today was frankly embarrassing. Dog-ate-my-healthcare-policy rhetoric. He simply doesn't know a thing about the subject, and doesn't care enough to learn. His entire presidential bid is based upon being in a certain place on a certain day.

Posted by: pseudonymous in nc | Jul 31, 2007 5:03:42 PM

You think that story was bad, you should hear about my trainwreck of medical issues (part of which are in the comment section of Drum's post).

Trust me ... Tobias' partner has it easy.

Posted by: Mark D | Jul 31, 2007 5:11:20 PM

I think Dr. Steven Bratman has the most prescient comment:

Back pain is indeed very often excruciating, but only in rare circumstances will getting an early MRI has any effect whatsoever on care. (Primarily, this occurs when sciatic-type pain is of such severity that emergency surgery is warranted.) For back pain as such, no matter how severe, there is no difference in outcome or course of care between an early MRI or getting one in six weeks.

The only benefit to the early MRI, in fact, is peace of mind of value for the patient is peace of mind. That's a value, certainly, but one that must be weighed against other uses of health care dollars.

At various times, independent medical commissions have set out guidelines for when an MRI is actually indicated in back pain -- and the answer is "almost never." In a rational health care system, the answer to most requests for an MRI would be "no."

Again, I do think our system needs to be massively overhauled. I do think a single payer system is a viable option. But this is not going to solve the problem addressed by this story: because, unless costs are going to continue to rise exponentially, someone has to ration care. The doctor and the patient have no interest in doing so -- rather the opposite. So, whether it's a bureaucrat, a health insurance employee or a Medicare reviewer, someone living in an undisclosed location will be making decisions like these. And people won't like it.

I hate to think that Tobias' partner is suffering; but back pain is one of the most complicated of health issues, hard to treat and prone to abuse by patients and doctors (it's one of the easy excuses for over prescription of pain killers for drug addicts - Rush Limbaugh, anyone? - non-specific back pain). I have a friend who has suffered horrifically since a car accident years ago, with multiple surgeries and hosts ofvisits to experts. Thank God she has good insurance (through my old employer), but the point is that little has been able to relieve her suffering, and that's with all things being optimal. The expense here is terrible; but insurance can't solve everything, and it's worth keeping in mind that back pain issues are a question of treatment for a problem that's often insoluable. And, what we're willing to pay for at that point is a question to consider for people pushing for single payer - there are limits, and there will be a point where someone has to say "no." And I think a lot of pro-single payer types kid themselves - and the argument - by saying that won't happen. It's something that needs to be considered, along with other issues.

Posted by: weboy | Jul 31, 2007 6:14:39 PM

weboy,

Your entire comment is pointless, as is that by Bratman. Charles was ordered by a surgeon to get an MRI. Apparently his surgeon thought having the results of an MRI in front of him would help him treat Charles.

Now, if you really want to discuss whether MRIs are effective or not, or when they are and when they aren't, then that's fine. But it seems to me that both you and Bratman are assuming several factors regarding Charles' condition which tilt the argument in your favor.

The plain facts, at least as we know them, is that an orthopaedic surgeon ordered an MRI, and a private insurer, whose profits depend partly upon their ability to deny care to their insured, has a 3-day wait in place for MRIs.

Does the estimable Dr. Bratman have sound medical reasons for why there should be a blanket 3-day wait for MRIs under that insurer's policy? Does every insurer have this policy? Have Dr. Bratman's medical commissions actually said that MRIs are not called for in cases of back pain, or have they said that there should just be a 3-day wait for authorization? 'Cause it sure seems to me that a 3-day wait for authorization has fuck-all to do with medicine and everything to do with discouraging people from getting needed medical care.

Posted by: Stephen | Jul 31, 2007 7:08:42 PM

I've never seen a MRI make anyone's pain go away, ever. I don't think a 3 day wait for an MRI is the worst medical story I've ever heard of. If people are discouraged from getting an ELECTIVE test, because they had to wait 3 days maybe they shouldn't have had it in the first place. The John Edwards story with the guy waiting 50 years to talk is a much better story. At least it has some pop. If this guy is mad now, wait until he tries to get on the surgery schedule and they tell him 2 months.

Posted by: Dingo | Jul 31, 2007 8:29:53 PM

I've never seen a MRI make anyone's pain go away, ever.

Really? Wow, that's great. And the part of the story that talked about the pain-relieving potential of an MRI was where, exactly?

Let's all try to stay on point here. An orthopaedic surgeon told his patient to get an MRI. Said patient's insurance company has a blanket 3-day waiting period for authorization of payment, which doesn't seem to be a medical decision at all.

Charles' pain was mentioned only because having to put up with an arbitrary, blanket 3-day authorization period is made worse when you're hurting. In that type of situation, every minute becomes quite important, and when a doctor's orders are delayed by a nameless, faceless bureaucrat for no apparent medical reason at all it's rather irritating.

In a national system, it would be much easier to establish guidelines for treatment based solely upon standard medical practices, rather than a particular company's 3rd quarter profit margin. Also, it would be easier to establish standard procedures for doctors and patients to appeal those guidelines.

Far from a naive belief that a UHC system would provide MRIs and ponies for everyone, most of us who want to reform America's healthcare system to UHC simply believe that cutting out the needless crap and idiosyncratic bureaucratic red tape would save time, money and heartache.

Going back to Dr. Bratman,

unless costs are going to continue to rise exponentially, someone has to ration care. The doctor and the patient have no interest in doing so -- rather the opposite.

That's just stupid. Everyone in the country is worried about the cost of healthcare. Those of us with insurance are worried about premiums, copays, deductibles, covered vs. non-covered medicines and procedures, coinsurance - you name it, we're worried about it. Those without insurance are so worried about costs that they simply don't go to the doctor until it's a life or death situation. Doctors are certainly worried about costs, because they're overhead goes up every year, but squeezing higher rates for services out of insurance companies - not just Medicaid and Medicare - makes squeezing metaphorical blood out of the proverbial stone look downright easy.

Everyone is worried about the rising costs of healthcare. That's why this has become such a big issue. In fact, the interests least likely to worry about rising healthcare costs are for-profit insurance companies. They know that the more costs rise, the more entrenched they become in the system, as more and more people turn to them to try and alleviate some of their risk. Private insurance companies have wet dreams about UHC plans that don't adequately provide cost controls, because that guarantees eternal profits for them.

Posted by: Stephen | Jul 31, 2007 9:41:27 PM

I've never seen a MRI make anyone's pain go away, ever.

And who, exactly, ever asserted such a thing?

Good job of totally missing the point. Well done.

Posted by: Mark D | Jul 31, 2007 9:54:20 PM

Again worst Insurance horror story ever. A 3 day approval is not likely to move him up the list if he does have a surgical problem. Maybe the insurance company has an in network MRI that will do it for 800 bucks, but instead since he had to wait 3 whole days he had to pay the charge not the actual negotiated cost. If my insurance plan had such a negotiated setup to save money for the rest of those paying premiums, I would have no problem with it rather than pay the actual out of network charge of 2400.

Posted by: Dingo | Jul 31, 2007 10:20:58 PM

No one has anyway of knowing if he got his MRI 3 days sooner if it would have ultimately got him out of pain or not

Posted by: Dingo | Jul 31, 2007 10:22:45 PM

Stephen, I'm less into arguing the specifics of this case here - since, as you point out, there aren't enough specifics about the man's condition to draw a lot of conclusions - than with the larger issues raised by this particular story: a) that MRIs rarely prove useful in figuring out back pain issues and b) that the question of who says no, how we say no, and when we say no to certain procedures doesn't magically vanish under single payer. If you don't like "automatic" 3 day waits for approval on MRIs now, will refusals for certain procedures, even certain MRIs, seem better under another system? I'm thinking... no. But there will be restrictions, and someone to enforce them, and that's something that needs to be faced. You talk about "standard medical practices" as if they're somehow the solution for insurance issues, when, in many cases, like, say, an unnecessary MRI, that's "standard medical practice" talking. Many doctors don't, at times, agree with "standard practice" or have adopted pratices that suit their own needs; it's not surprising that given a choice between an outside evaluator and, you know, one's own doctor, many people will think their doctor should be the authority, and screw "standard medical practice". Again, that's not magically going to change under Single Payer. Now, am I some defender of insurers and HMOs? No, there's plenty of bad there... of course, in healthcare, there's plenty of bad to go around, and I haven't and don't plan to sign onto the fashionable politics of the left that make Insurers akin to Satan, and much of the rest of healthcare systems out to be saints. Lots of things about our healthcare systems - Medicare, Medicaid, Private Insurers, Hospitals, Doctors, Rehab Services... I could go on - need reforms. Insurance alone is not the problem, or the solution to what ails us.

Finally, I'd point out that your "everyone is concerned about rising costs in healthcare" is beside the point - you've offered absolutely nothing about how, actually, costs would be contained under an alternative system. This is often where progressive single payer advocates pull out "administrative savings" but that answer is about as useful as when conservatives trot out "tort reform" - almost every systemic change in healthcare has been promised to "reduce administrative costs" and help "contain the system" and what we've learned this far is that "the system" learns, each time, to work with the new systems and costs start heading north yet again (that was, for one thing, the promise of HMOs and PPOs, which were initially successful in containing costs). I'm most sympathetic to the notion taht what needs to be removed from healthcare is the profit motive; however, turning our healthcare system into not-for-profit from where we are now is especially pie-in-the-sky. Given that, I think we have to face up to what can realistically be done to control costs... and one of them, which people need to face, is that unnecessary procedures will come under heavy scrutiny. And it's who get to make that definition of necessity that will be key. And that, really, not some in-depth evaluation of MRI process, is my point.

Posted by: weboy | Jul 31, 2007 10:27:43 PM

the question of who says no, how we say no, and when we say no to certain procedures doesn't magically vanish under single payer

No one has said that it would. Except you, and only then to shoot the idea down.

Many doctors don't, at times, agree with "standard practice" or have adopted pratices that suit their own needs

A nationalized system of some sort would make it far easier to both allow doctors to challenge the standards when necessary and make it less likely that doctors will deviate from accepted medical norms just for the hell of it. Confusion hardly contains costs.

Finally, I'd point out that your "everyone is concerned about rising costs in healthcare" is beside the point - you've offered absolutely nothing about how, actually, costs would be contained under an alternative system.

That's because my statement was in response to a direct claim by Dr. Bratman, who you quoted approvingly, to wit: unless costs are going to continue to rise exponentially, someone has to ration care. The doctor and the patient have no interest in doing so -- rather the opposite.

The claim here, in case it's hard to see, is that patients and doctors are not only unconcerned about rising costs, but have an incentive to blithely dismiss them. Therefore, one can assume - correctly - that I didn't offer any solutions to the problem because that's not what was being discussed.

This is often where progressive single payer advocates pull out "administrative savings"

Except that I didn't, so I fail to see why you brought it up.

nd one of them, which people need to face, is that unnecessary procedures will come under heavy scrutiny. And it's who get to make that definition of necessity that will be key. And that, really, not some in-depth evaluation of MRI process, is my point.

Ok, so can the insurance company's decision to impose a 3-day authorization waiting period be explained medically? If it's unnecessary, then it shouldn't be covered at all, or perhaps it should be covered at a reduced rate (higher copay). Or, perhaps the insurance company could have responded with a request for more information from the doctor as to why he thought an MRI would benefit this patient in this situation, when the majority of patients in this situation wouldn't.

There is no problem here with UHC advocates demanding free MRIs for everyone who wants them, or even pie-in-the sky dreams of nonprofit healthcare or saving $100 trillion on administrative costs. The problem is an insurance company that at the very least appears to be arbitrarily forcing a waiting period on a procedure for no medical reason at all. That's a problem we're having right now, which is a far cry from the problems that we might have in some imagined UHC system. Perhaps those of us who wish to see some sort of UHC system could worry more about designing a system that addresses these types of problems instead of blaming people for not already fixing them.

Posted by: Stephen | Jul 31, 2007 11:01:27 PM

Regarding the advisability of doing an immediate MRI because the surgeon ordered it. Does anyone know if that surgeon had a financial interest in getting the MRI test?

Payers (and here I mean CMS, not just private insurers) have rightfully become quite suspicious of physicians who own imaging equipment. Those who get some kind of reimbursement from imaging decide (shockingly) that their patients need lots more of those tests than do physicians who don't have a financial stake. This has been documented by multiple studies.

The NYTimes had a decent story on how our undisciplined FFS system is the single largest cost driver for medical care, and why we pay 16% of GDP for health care while our peer nations pay more like 10%. The admin and profits from private insurers pale in comparison. Not to say that they don't make a difference in the tens of billions of dollars. But perverse FFS incentives have added hundreds of billions in costs that never had to be there.

For progressive to focus only on private insurance may be tactically smart in the short term (people already hate insurers and may be led to support universal healthcare more easily), but it is a colossal mistake as a matter of economic reform and the long-term sustainability of universal health care.

Posted by: jd | Jul 31, 2007 11:07:34 PM

...except that practice decisions - and questions about practice decisions - can seem arbitrary from outside; you ask for a "national standard", but things are already moving in that direction with the NCQA - and one of the biggest points of resistance to ever larger, more nationalized and comprehensive "standards of care"... is doctors, who don't like being dictated to; it also belies the fact that the energy around creating these standards... comes from HMOs and Insurers, who then get categorized as "the enemy" when trying to enforce them. Something of a vicious circle there. Again, I don't know why that particular insurer with that particular decision making process waits to evaluate MRI decisions - it could be as malevolent as it "appears", or a "standard of practice" approach... I haven't seen enough to know one way or the other... nor have you, apparently. As for the rest, I was mostly anticipating arguments which I've seen from others; I'm happy not to have to re-argue them.... but the question does stand, even if you want to elide past it - many of the "horror stories" about insurers have to do with medical issues that are quite complicated, involve differences over best practices, and have to do with attempts to control costs. None of that can really be ignored, and oversimplifying th situations into "patient good, insurer bad" often misses key elements that need to be considered. Nor can proposed solutions to the insurance question ignore that we will still have people turned down, procedures that seem necessary to individuals and their doctors being turned down, and a debate about controlling costs (and no, patients and doctors are not "unconcerned" about costs, but a considerable amount of the misconceptions about insurance in this country have to do with unreasonable expectations about care irrespective of cost. And that, too, needs to be addressed).

Posted by: weboy | Jul 31, 2007 11:17:06 PM

one of the biggest points of resistance to ever larger, more nationalized and comprehensive "standards of care"... is doctors, who don't like being dictated to"

I understand that you enjoy being contrary for its own sake, but give me a break.

First, doctors are already "dicated to," from multiple private insurers, Medicare and Medicaid, their malpractice insurance and the legal departments at hospitals. The problem is not that someone is going to dictate standards to doctors. The problem is that there are so many different entities dictating standards and restrictions to doctors that they sometimes don't know whether they're coming or going.

Second, you're the one who brought up the entire issue in the first place. You said that at some point someone needs to say "no." I suggest that within a UHC system we establish some sort of coherent standards for care - something that is already done, but in endless variations. We also establish procedures for bucking those standards - again, something that is already done, but in endless variations.

At some point why don't you quit sniping and engage what people actually say? Do you think we should have national standards? Why or why not? I'm of the opinion that such standards of care are essential to any cost control strategy. Obviously insurers feel the same way. The difference is I want those standards to be based solely upon sound medical practice and not also shareholders, quarterly earnings reports and executive bonuses.

Endlessly repeating the same lectures about cost containment doesn't actually solve anything, nor does it actually address what Ezra and the clear majority of commenters at this blog say. The only examples of dismissing the problem of cost come from those who wish to hold up such examples and then tear them down as not sufficiently serious - straw men.

The reason that insurance companies are so demonized is because part of the problem with rising costs is the amount of money that goes to profits and to finding new ways to deny benefits to the insured. No one believes that we can get rid of the private insurance industry at the stroke of a pen, nor does anyone believe that we can endlessly fund a UHC system merely by removing profits from it.

But we can start to exert some control over the way decisions are made by reforming both the way insurance companies are able to operate and, as jd pointed out, the way in which our FFS system encourages certain medical practitioners to overprescribe treatments and procedures that increase their personal incomes.

As I said before, these are problems that we currently have instead of problems that we might have, so it makes sense to focus on them. You can worry about phantom problems all you want, but don't blame the rest of us for focusing on what's really happening.

Posted by: Stephen | Jul 31, 2007 11:41:41 PM

a) that MRIs rarely prove useful in figuring out back pain issues

Actually, an MRI is one of the ONLY ways to find out of back pain is a structural (and, thus, a serious) issue, while X-rays only show about 20% of back problems.

Granted, an admittedly large number prove to be some guy who pulled a muscle that just won’t heal, or has an occasionally pinched nerve.

But to state that MRIs are “rarely useful” is just flat-out wrong. A little story to prove it (WARNING: Self-centered sob story ahead!):

I first had back pain in 1998. Over the course of the next five years I saw 12 different doctors, each of whom were told by the insurance company (an HMO at the time) to take the approach Dr. Bratman and you advocate -- back pain effects lots of people, so MRIs aren't all that important. Here's some Vioxx and a few muscle relaxers. And use a heating pad. Thanks!

BUT ... If I had been given an MRI when my back first started to hurt, they would've discovered I had degenerative disc disease and treated it without surgery.

Instead, my discs between L4-L5 and L5-S1 were just ... gone. I had three disks pounding on top of each other for five years. While I certainly don’t pretend to know your life history, unless you’ve gone through something similar, I can almost guarandamntee you have no idea of how much that hurts. No. Idea.

Two surgeries later and I'm partially disabled and saddled with $15K of bills (yes, I had insurance and yes, it pretty much sucked ... although there's a LOT more to the story with those asshats). I also have permanent nerve damage due to the problem not being treated on time – so much so that I can rarely pick up my son.

Again, I don’t know you, so I’m not sure if you’ve ever tried explaining to a toddler that you physically can’t do something. If you haven’t, I can assure you that it ain’t easy. In fact, it’s both humiliating and heartbreaking.

And all because the HMO I had at the time wanted to save a few bucks on an MRI.

In the end, though, it’s kind of funny—the first surgery cost my original HMO about $135K, rather than the $3,000 MRI.

/end sob story

So … while I respect your opinion, expecting a simple test—using equipment that, while expensive, isn’t in any way new, uncommon or hard to find—to be given in a timely manner in order to find the solution to a medical issue isn’t exactly asking for the world, no matter what it finds.

Posted by: Mark D | Jul 31, 2007 11:42:39 PM

Mark D,

The situation you describe (from this remove) sounds utterly dysfunctional and to have produced a bad result for everyone except whoever ended up getting paid that $135K for the surgery. That said, the plural of "anecdote" is not "evidence," by which I mean that horror stories will exist for any system.

Every system (or non-system) will ration care in some way. If it isn't done by ability to pay, it will be done according to some guidelines about the expected cost/benefit ratio of treatments. And sometimes those guidelines will be wrong in particular cases. It's inevitable.

So the question is: how do we know the insurer's guidelines were bad? We know that in this particular case they produced the wrong action, but perhaps in general the MRI guidelines were reasonable. Would you have received the MRI right away in England? In Germany? In Canada? In Japan? I doubt the answer is the same for all these countries.

Finally, I completely accept that I have no real comprehension of the suffering you have endured. Being on the tail end of the Bell Curve is a bitch when the guidelines are designed for those in the middle.

Posted by: jd | Aug 1, 2007 1:39:05 AM

While I'm sorry you ended up with surgery. You're case will not change with any system. No one is taught to order MRIs when "the back first starts to hurt". That no matter what part of the country you are in is not standard of care and shouldn't be taught anywhere. Every physician is taught that in acute back pain 90% of patients are completely better in one month, so ordering MRIs on everyone is a collosal waste of time and money. Your first doc should have ordered it after you returned in one month and was still in pain. I've never been told no by an HMO on a MRI or CT scan if I ordered it. I'm not sure what they could have done for you nonsurgically. As far as I'm concerned people need to equate an MRI with surgery, because if you are not prepared to undergo an operation why waste everyone's time and money with a MRI. My knee hurts all of the time I know I have a torn meniscus, but I don't want a MRI, because I don't want surgery.

Posted by: Dingo | Aug 1, 2007 1:53:58 AM

Stephen - Let me be clear: I'm in favor of national stndards. I want them to be based on "sound medical practice" - the problem I think, is that such standards are going to be problematic and upset some people, especially doctors (who, again, don't appreciate being told how to practice), but also some patients (who have, in most cases, no real way to evaluate whether the care they receive fits a "standard" practice or not). And, despite your hopefulness, those standards will not magically make everything else make sense - some people - like Mark, I'd say - have cases that fall in greyer areas where a"national standard" might deny a procedure that in a particular case would make sense. That's the problem. You need standards... and then you need flexibility. Focusing, as we do, endlessly on payments and permissions requires us to put in place rules, and to have them apply in a fairly fixed way. That's not, really, how healthcare works. That's the dilemma.

I bring all of this stuff up, because I do feel passionately about healthcare reform. But if you ask what I want, what I want is to figure out how people get the care they need, not get bogged down in a lot of falderal about who pays. That's why I think the question of demonizing insurers is pertinent - demonizing insurers and making money our focus... mean that we're not talking about healthcare. We're talking about money. You continue to insist that the only "realistic" way to look at the state of healthcare is through the lens of insurer practices. There are other lenses. And other realities. And those need to be dealt with, as well.

Posted by: weboy | Aug 1, 2007 10:19:27 AM

You continue to insist that the only "realistic" way to look at the state of healthcare is through the lens of insurer practices.

Ok, now I'm understanding you better. What I see you saying is that the present problems don't matter as much as the problems you anticipate having in the future if X, Y and Z happen first. What I'd like to see is a comprehensive attempt at reforming the US healthcare system, mainly because I don't think we're all that close to UHC in any form.

We do need to work toward UHC. But we also need to address the abuses and problems that we have right now. One of our biggest problems is that insurance companies are able to make decisions about coverage and care that don't even have a tangential relationship to actual medical practice.

To be clear, making a decision, based upon the relationship between effectiveness and cost of MRIs, to not allow an MRI unless the doctor can prove extenuating circumstances is making the decision upon medical evidence. It's not that I don't want cost to be a part of it. What I don't want is the former practice of insurance companies to withhold payment from practitioners for months and months in order to earn interest on money that should have been paid out. What I don't want is the myriad of bureaucratic roadblocks we currently have which have no basis other than discouraging patients and doctors from seeking care.

Again, no UHC advocate that I've ever heard or read has ever suggested that rising costs aren't a problem, or that people will be able to get whatever treatment they want and it will all be paid for by the magical Socialized Medicine Fairy. I'm not sure how many times I'll need to say this. Senator Wyden knows it's a problem, John Edwards knows it, Barack Obama knows it, Hillary Clinton knows it. Everyone knows that rising costs will always be a problem.

But what people need to understand is that the spiraling costs are a factor of our present system. To use a business cliche, the US healthcare system is perfectly designed to create the outcome we are seeing: millions without insurance, skyrocketing costs, poorer health outcomes than pretty much any other industrialized nation. A UHC system will need to address these problems. But it actually would have the ability to address these issues, unlike our current system. Remember, insurance companies put restrictions in place not to keep prices down, but to preserve profit margin. If they can make a profit in a swift-rising cost environment, they will do nothing to control costs.

Focusing on who pays is perhaps unfortunate, but necessary. As you obviously know, we already have quite a few mechanisms in place to tell doctors how to treat their patients, whether they like it or not. Solving the problem of who pays would actually give doctors way more freedom to practice medicine instead of running a complicated payment-collection business and having to rewrite their orders over and over to fit a particular company's rules.

I mean really, how much time do American doctors spend messing around with the ins-and-outs of actually getting care approved and paid for under our current system? Wouldn't it be great for everyone to just know what the standards are - and again, how to deviate from those standards when the case calls for it?

Posted by: Stephen | Aug 1, 2007 11:01:56 AM

Let me just say that this thread is the reason I love this blog -- incredible intelligent debate (making me feel pretty damn stupid ... okay, not hard to do, but still ... ).

Every system (or non-system) will ration care in some way. If it isn't done by ability to pay, it will be done according to some guidelines about the expected cost/benefit ratio of treatments. And sometimes those guidelines will be wrong in particular cases. It's inevitable. --jd

I don't disagree at all. It sucks that I'm the one for which it was wrong, but I understand that.

So the question is: how do we know the insurer's guidelines were bad? We know that in this particular case they produced the wrong action, but perhaps in general the MRI guidelines were reasonable. --jd

I don't find them reasonable because the care of the patient was secondary to costs.

Just like the story that started this thread, what good is having some sort of mandatory waiting period on a test ordered by a doctor? Honestly. Unless the MRI in question was owned by the doctor (thus creating a conflict of interest), I don't see a logical argument.

Would you have received the MRI right away in England? In Germany? In Canada? In Japan? I doubt the answer is the same for all these countries. --jd

I would've had the MRI right away with a different health plan (such as my current one, which is three times more expensive, BTW). And I doubt that any of the countries listed have a system that makes people wait five years.

As far as I'm concerned people need to equate an MRI with surgery, because if you are not prepared to undergo an operation why waste everyone's time and money with a MRI? --Dingo

And that right there is the problem with our current system: MRIs don't take all that long, yet people act as though you need to prep for months in advance. Costs are discussed, ignoring the fact that clinics and hospitals charge more than the machine costs in order to make a profit off of it, meaning there's room for cost savings if we took making maximum profit out of the equation.

These are the problems with a profit-driven system.

My knee hurts all of the time I know I have a torn meniscus, but I don't want a MRI, because I don't want surgery. ---Dingo

Uh ... I didn't want surgery. I had no choice. :-)

You know ... I understand that no system is perfect. I get it. In fact, I'd guess that everyone gets it. There will be trade-offs, care will need to be "rationed" in some way (although I may frame that a bit differently), and any UHC-type plan will cost great big globs of cash. I also understand that medicine isn't an exact science—doctors make mistakes, every patient is different, etc.

But I really can't think of any reason anyone, anywhere, under any other system, should have to go through what I did. And the only reason I went through what I did was because of our profit driven model.

While I may be on the end of the "bell curve" (as jd wittily put it), there are, in fact, millions of people who have had similar stories. And what I find most repulsive is that there are people (not necessarily here, mind you) that treat us as exceptions to the rule, and nothing more than the collateral damage of a fundamentally broken system.

Posted by: Mark D | Aug 1, 2007 11:51:45 AM

What I see you saying is that the present problems don't matter as much as the problems you anticipate having in the future if X, Y and Z happen first. What I'd like to see is a comprehensive attempt at reforming the US healthcare system,...

The present problems matter tremendously; what also matters is that the solutions being advocated don't necessarily address the problems. I too would like a comprehensive reform. I tend to think, though, given the variety of health care systems and practices out there, that even talking a "comprehensive" solution neglects that what seems like a solution to part of the problem makes other problems worse.

Again, no UHC advocate that I've ever heard or read has ever suggested that rising costs aren't a problem, or that people will be able to get whatever treatment they want and it will all be paid for by the magical Socialized Medicine Fairy. I'm not sure how many times I'll need to say this. Senator Wyden knows it's a problem, John Edwards knows it, Barack Obama knows it, Hillary Clinton knows it. Everyone knows that rising costs will always be a problem.

People who are involved in the decision making and proposal writing understand the scope of the problem. The general public, I'd argue, does not; what they understand is that insurance used to (as some like to believe) pay for a lot of things and now it doesn't. What people don't understand is why "necessary procedures" (using an expansive definition of "necessary," irrespective of cost) are no longer covered. Providing a variety of examples about how Grandma, or your boyfriend, or that poor man in West Virginia, didn't get something vitally needed tends to play into this worldview. If we are going to have a UHC plan (and I have my doubts about how workable that is, still), we will need to explain not just what they will get from it, but what they won't, and why. Absent that, you've replaced the perception that our current system sucks for a perception that what we'll replace it with sucks worse.

But what people need to understand is that the spiraling costs are a factor of our present system. To use a business cliche, the US healthcare system is perfectly designed to create the outcome we are seeing: millions without insurance, skyrocketing costs, poorer health outcomes than pretty much any other industrialized nation. A UHC system will need to address these problems. But it actually would have the ability to address these issues, unlike our current system.

Again, you say spiraling costs can be addressed under UHC without beginning to suggest how. I am not clear - honestly - on just what UHC gives us in regards to controlling costs that isn't already there, and what we already have is failing to control costs now. The pressures on healthcare professionals and institutions like hospitals to make money will not just go away, and that's where the upward pressure on costs really comes from.

As you obviously know, we already have quite a few mechanisms in place to tell doctors how to treat their patients, whether they like it or not. Solving the problem of who pays would actually give doctors way more freedom to practice medicine instead of running a complicated payment-collection business and having to rewrite their orders over and over to fit a particular company's rules.

I mean really, how much time do American doctors spend messing around with the ins-and-outs of actually getting care approved and paid for under our current system? Wouldn't it be great for everyone to just know what the standards are - and again, how to deviate from those standards when the case calls for it?

You can't tell people, especially doctors, that you have a set of standards that are expected and then tell them that they can deviate from them as they see fit; that's part of what we have now. Implementing a standard of care means taking from doctors a lot of the autonomy they currently have to treat in ways that deviate from that standard. Yes, some rules from insurance companies are about profit and payment; but Medical Directors at HMOs and Insurers are also the brake-point for highlighting not just waste and fraud, but deviation from best practices that they can see because of the amalgamation of numerous practice choices. Solving some problems about who pays will not eliminate the evaluative role of The Payer who takes over, nor the need for enforcement of standards, even if, in theory, it simplifies beaurocracy (and that, too is something I find rather skeptical). New names, same problems. That's what brings me back to where I started: I want a solution to the healthcare crisis; but I think we need to understand the problem, and understand how a solution represents actually solving something.

Posted by: weboy | Aug 1, 2007 1:30:41 PM

"And that right there is the problem with our current system: MRIs don't take all that long, yet people act as though you need to prep for months in advance. Costs are discussed, ignoring the fact that clinics and hospitals charge more than the machine costs in order to make a profit off of it, meaning there's room for cost savings if we took making maximum profit out of the equation."

The reason they don't take long is because of the profit incentive. If you eliminate profit, who's going to buy a 1.5 million dollar MRI and who decides what hospital is going to get one and what one doesn't. The one that contributed most to their representative? I think we have the radiology infrastructure right now to take care of everyone, physician and nurse manpower for everything else that's a different being. If you eliminate profit entirely you can't guarantee that we will still have enough scanners years from now.

Posted by: Dingo32 | Aug 1, 2007 3:40:53 PM

Dingo--
I don't think I made myself clear. Sorry 'bout that.

I'm not opposed to hospitals, insurance companies or anyone else making a profit.

What I am opposed to is them making the maximum amount of profit at the expense of quality care.

That's why I've advocated (long before Michael Moore proposed it) that our health system become a not-for-profit industry. You can still make money (ask anyone who works for a charity), but it stops becoming the end all, be all.

Hope that clears things up a bit.

Posted by: Mark D | Aug 1, 2007 4:00:12 PM

Thanks,
I do agree I see no purpose in putting anything involved with healthcare on Wall Street in the form of stocks and I see no discernable positive outcome for the public with CEO bonuses and board member salaries. I think there is a way to legislate that out of our current system but keep some of the benefits of a private system such as the profit incentive for hospitals and providers.

Posted by: Dingo | Aug 1, 2007 4:16:00 PM

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