What would you put in a healthcare reform bill

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kiryan
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What would you put in a healthcare reform bill

Postby kiryan » Thu Dec 17, 2009 10:28 pm

Lets write our own healthcare reform bill. Feel free to add your own "amendments"

1) Allow drug reimportation.

If Pzier wants to sell drugs cheaper to Canadians, why shouldn't we just import US drugs from Canada?

2) Tort reform including: a reduction in litigation by raising the standards, a reduction in awards by capping them.

You can sue doctors for just about anything and call it malpractice, and win an absolute fortune.

3) Prevent insurers from dropping patients unless clear fraud occured related to pre-existing conditions at sign up.

The practice of dropping coverage for minor ommissions when signing up for coverage would be barred.

4) If you are continuously insured by an insurer for 2 years, pre-existing conditions coverage exceptions are barred.

If you have cancer in remission, don't disclose it to the insurer and are continuously insured by the company for 2 years, they can't drop you or deny coverage.

5) Eliminate anti trust exemptions for insurance companies

6) Federal law trumps state law.

State laws are far too often used as barriers to entry, protecting favored insurance companies from external competition.

7) Address worker shortage issues

Train more doctors in the military
Train more nurses in the military
Create and fund "free" government schools to train doctors and nurses. Do it in the military if you need to.
Reduce the difficulty of completing medical training by 33% until we have enough trained and certified professionals in the work force then ratchet them back up.

8) Create a national medical record system / standards.

Patients would authorize providers individually to view their medical record in distinct areas (mental health being separate).

9) Create a national clearing house / standards for medical claims

The medicaid / medicare system is ridiculous, but it would be a lot less ridiculous if it was national and everyone routed their claims through it directly instead of through state level medicaid systems or through private insurance.

10) Require Healthcare providers and Insurance companies to provide clear up front information on what something will cost.

Eliminate the whole I agree to pay whatever you charge that my insurance doesn't cover style agreements that doctors require before they see you.
I got charged $40 for the "new mothers care pack" on our last baby. It was a little diaper bag of crap that I wouldn't have paid $40 for but no one asked me if I wanted to buy it.
I got charged $3k because we were referred to an out of network MRI by our in network doctor.

11) A national insurance exchange

Add in a pick your plan marketplace where you select what you want covered and who covers it and insurers can offer you tailored coverage depending on your demographics. For example, get your cancer coverage from Blue Cross, get your vagina covered at Regents, get your general practitioner coverage from United.

12) Allow hospitals to refuse care to individuals who have visited their facility more than 4 times in 2 years and not paid for it.

13) Revise drug patent laws to eliminate changing a drug slightly and claiming a new patent / exclusivity period

ADDITIONS AND EDITS

14) change how health insurance is offered by employers

Instead of take the company plan or leave it, require employers to give employees the benefit in voucher form. So, if my company is willing to pay $1,000 of a $1,500 premium for my healthcare insurance, I can opt not to buy their insurance and go on an insurance exchange and buy my healthcare using the company portion of it. Or, I should be able to bank the $1,000 a month into a "health spending account" which can only be used for health care / insurance and "self insure". Realize that because not everyone opts into these programs, the benefit amount might have to be reduced from $1,000 to say $800 to make the overall costs stay the same for the company. This of course would be pre-tax $$.

This would dramatically increase competition between insurers I think. Also, it would dramatically reduce the # of people negotiating contracts, every insurer has a whole department of people doing this and every company has someone who spends several weeks every year looking for a better deal.
Last edited by kiryan on Fri Dec 18, 2009 6:48 pm, edited 1 time in total.
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Re: What would you put in a healthcare reform bill

Postby Ashiwi » Fri Dec 18, 2009 3:47 am

1) Allow drug reimportation. I very heartily agree with this. The main two problems I really see with it immediately are the issue with fraud, since non-US providers wouldn't be held to our regulations, and the issue with quality, for the same reason. It's ridiculous to pay over $100 in the US for the same drug you can get in Canada for $30. My biggest fear would be that for the fraud/quality issue, a whole new form of wholesaler would be created which would be susceptible to driving international prices up because of taxes/tariffs, and because the large drug companies would more easily be able to manipulate pricing structures if that happens (if such legislation is passed, that's where my next investment dollars are going).

2) Tort reform. That would fix a world of woes in the medical industry.

3) Create a national standardized high risk pool specifically for the chronically uninsurable who can't afford the premiums. Yes, it would be a sort of "public option," but would be restricted to those who have no present access to group insurance or medicare/medicaid. Federal law already prevents insurance agencies from dropping high risk patients from employer-funded fully insured policies.

4) Create a national records bank that all providers would have to utilize, so that the issue of "minor omissions" becomes a thing of the past. Take the guesswork and deliberate omission out of pre-existing conditions. Make it easier for providers to coordinate their efforts.

5) Create standardized regulations on how insurers respond to the coverage of services and items previously considered experimental and/or investigational, but since approved by Medicare or the FDA as reasonably medically necessary for certain conditions.

6) Rewrite HIPAA. It's a freaking monster that creates piles and piles of red tape and prevents providers and insurers from serving their patients and members more often than is reasonable. Dealing with HIPAA regulations the way they are written costs the healthcare industry an unnecessary fortune.

7) Increase the fines against insurers if they are found non-compliant in matters of timely processing on written inquries.

8) Allow insurers to reasonably assess fees against providers who intentionally clog the system and drive up costs. It's not unusual for providers to submit multiples of every inquiry (I've seen one provider who submitted each claim 15 times, and saw his patients a minimum of once per week). In cases of system abuse the cost in manpower to respond to these inquiries adds up to hundreds of thousands of dollars every year, which goes straight back into premiums.

9) Create a standard inquiry submission system that allows individuals and providers to track their submissions. If Federal Express can do it, why not the healthcare industry?

10) Everybody will hate this one. Require general hospitals with greater than a specific amount of rooms to allocate only a set percentage of services to highly specialized high-dollar care. Hospitals are falling over each other to try to be number one in every specialty, and the high dollar toys and specialty facilities are costs that are passed to the patients and insurance companies. Every hospital should be equipped for emergency medical care, but not every hospital needs a cyber knife. To back this regulation up, require that the revenue of a general hospital be retained within the facility, or they'll just open satellite locations and sink their general fund into them. Require the bulk of the costs of highly specialized treatments and equipment to come directly from the fees charged for these services.

11) Require facilities to price drugs at the AWP, or within a percentage of the AWP, plus a standard dispensing fee.

12) Require insurers to accept the credentials of physician assistants and RNs for a wider array of non-specialized services.

As far as I know, federal law already trumps state law, however, each state writes regulations on how to deal with federal laws, and laws on top of federal laws.

I don't think I would support a national clearinghouse for private insurers. As there is more movement toward the standardization of other aspects of the insurance industry, one of the largest selling points left to agencies will be customer service, and it's difficult to sell yourself as having better customer service when everything is going through the same entity. You might as well go back to a single public option at that point.

Now on cost of healthcare, here's the thing ... requiring regulations on healthcare providers that would successfully bring the cost of healthcare down to a reasonable and sustainable level would mean removing a big chunk of their freedom to operate as private entities. Republicans would balk every step of the way. In some ways I understand that, but the rate at which healthcare has been blowing itself up, there's no way the healthcare system we have now can continue for much longer.

If you want to bring down the cost of premiums, you HAVE to bring down the cost of healthcare. If tort reform is instituted, malpractice coverage costs would have to be forced down because business rarely lowers its rates willingly. Once malpractice coverage isn't the big excuse, the cost of services would have to be addressed in some form. At this point I'm really iffy about what it would take to reduce healthcare costs, because any steps would require regulating what providers can charge for a service.

The cost of creating a standardized pricing index for the entire nation which would be an enforceable entity would mean the government would have to adopt the jobs of several organizations who presently perform this function with widely varying results. Services would have to be priced according to an international scale and allowed cost-of-living adjustments for the area served. The index would have to be maintained and updated annually. The pricing index would have to include a sliding scale to take specialty into account. The cost of a venture like this would be enormous, and the margin for error would be vast.

On top of that, providers would have to be required to accept the pricing index, and very few would want to. A federal agency telling a hospital they can only charge $250 to remove a boil on your butt isn't going to magically make the cost of supplies and utilities go down.

So yeah. There's a tiny fraction of the more acceptable and less radical alternatives.
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Re: What would you put in a healthcare reform bill

Postby Todrael » Fri Dec 18, 2009 3:54 am

Here's another discussion on the same topic, in the same format, no less.

My favorite from his list is #3, "Boost subsidies to medical R&D by more than the Obama plan will do. Establish lucrative prizes for major breakthroughs and if need be consider patent auctions to liberate beneficial ideas from P > MC."
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Re: What would you put in a healthcare reform bill

Postby Ashiwi » Fri Dec 18, 2009 4:58 am

Total cost transparency may not be entirely impossible, but it's definitely unrealistic, and asking it from an insurer is beyond unrealistic. An insurer has no way of knowing what services are going to be filed until the claim has been received, and a provider isn't entirely sure what services will be filed until the procedure has been completed. Either way, if one of those entities gives a patient a definite price on a procedure, and the procedure ends up costing more, guess who's probably going to get sued. It'll be whichever one supplied the quote.

Try to remember that if an insured member called in and asked me how much an inpatient mastectomy ran and I gave her a DRG quote of $12000.00 (this is a made up number), then told her that we would pay $10,000.00 after her out-of-pocket was met, I would be making myself and my company responsible for the cost of that mastectomy. If there were complications, or if the anesthesiologist was out-of-network, or if the provider filed a different diagnosis, or had to use a certain type of drug due to a patient's allergies, or specific types of supplies due to a facility's limitations, it could change the end cost. And, believe it or not, if a member got a quote like that then lost their insurance before the surgery, they can still sue to have the insurance pay for the service.

Insurers can give general cost estimates on commonly performed procedures, but anymore they pretty much have to be sent in writing with pages of disclaimers, or kept in an online database with disclaimers built in, because it's impossible to secondguess the providers.
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Re: What would you put in a healthcare reform bill

Postby kiryan » Fri Dec 18, 2009 6:01 pm

You say its impossibly hard to do it as an insurance company? Try being the consumer. At least an insurance company understands the lingo and knows who is in or out of network. The consumer really has no idea and really even with a lot of research by a smart person still can't get it right. I make Laurel call the insurance company and the doctors office and find out how much its going to cost me before EVERY appointment. 50% or more of the time she totally gets it wrong and basically 100% of the time the insurance company won't say anything other than its in your benefits book (whcih she then goes over with the person on the phone).

If you made this a requirement, they would figure out how to get it done. There is no reason why we can't have real time pricing in the Doctor's office based on your insurance and your coverage. There is no reason why when the nurse comes in and gives you a bag of "free shit" they can't tell you that your insurance will be billed $40 for it.

How can we manage costs if the people making the decision on whether to consume a service isn't told how much it will cost?
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Re: What would you put in a healthcare reform bill

Postby kiryan » Fri Dec 18, 2009 6:38 pm

3) Create a national standardized high risk pool specifically for the chronically uninsurable who can't afford the premiums. Yes, it would be a sort of "public option," but would be restricted to those who have no present access to group insurance or medicare/medicaid. Federal law already prevents insurance agencies from dropping high risk patients from employer-funded fully insured policies.

I might support this kind of a public option for people found to be uninsurable. It keeps the rest of our premiums from being artificially higher and increases the visibility of how much this costs.

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5) Create standardized regulations on how insurers respond to the coverage of services and items previously considered experimental and/or investigational, but since approved by Medicare or the FDA as reasonably medically necessary for certain conditions.

I agree, but the regulation I would seek would be, experiemental is not covered. These are people who have tried everything generally and this is their last chance at preserving their lives... If we've tried everything, it is time to die.

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8) Allow insurers to reasonably assess fees against providers who intentionally clog the system and drive up costs. It's not unusual for providers to submit multiples of every inquiry (I've seen one provider who submitted each claim 15 times, and saw his patients a minimum of once per week). In cases of system abuse the cost in manpower to respond to these inquiries adds up to hundreds of thousands of dollars every year, which goes straight back into premiums.

... I'm not familiar with this problem, I'm hesitant to support it. Coming from the provider perspective primarily, if insurers would handle their claims timely and cut the crap we wouldn't have to submit claims 15 times. What organization wants to pay people to submit claims extra times? They are doing it to make sure they get paid because insurance comapnies maze of rules make every claim a crapshoot.

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10) Everybody will hate this one. Require general hospitals with greater than a specific amount of rooms to allocate only a set percentage of services to highly specialized high-dollar care. Hospitals are falling over each other to try to be number one in every specialty, and the high dollar toys and specialty facilities are costs that are passed to the patients and insurance companies. Every hospital should be equipped for emergency medical care, but not every hospital needs a cyber knife. To back this regulation up, require that the revenue of a general hospital be retained within the facility, or they'll just open satellite locations and sink their general fund into them. Require the bulk of the costs of highly specialized treatments and equipment to come directly from the fees charged for these services.

I like it and I don't like it. This is a problem, hospitals trying to extend their geographic reach so they can generate more referrals for their high $$ specialities. Every hospital wants a cancer wing and a cardiology wing because they are such huge profit centers. The problem is that these specialities are so highly paid while they lose money on general care. If general care was paid better, you'd see more balance.

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12) Require insurers to accept the credentials of physician assistants and RNs for a wider array of non-specialized services.

ABSOLUTELY AGREE.

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As far as I know, federal law already trumps state law, however, each state writes regulations on how to deal with federal laws, and laws on top of federal laws.

Federal law may trump state, but states can still add a ton of extra stuff. I'm basically talking about federal law flattening the market to prevent states from creating artificially high barriers to entry for whatever reason.

Its a states right issue... but all my suggestions are predicated on the belief that we are or will essentially turn healthcare into a right which I disagree with but ... You couldn't abolish slavery state by state, I don't think you can reform healthcare state by state.

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I don't think I would support a national clearinghouse for private insurers. As there is more movement toward the standardization of other aspects of the insurance industry, one of the largest selling points left to agencies will be customer service, and it's difficult to sell yourself as having better customer service when everything is going through the same entity. You might as well go back to a single public option at that point.

You probably have no idea how much it costs and how impossible it is to get hooked up with every insurer as a provider. We use one clearing house for 80% of our stuff, another for another 10% and the rest we have to paper bill. We pay for all of these and its a lot of extra knowledge and training the company has to absorb. With a national clearing house, I'd only have to set one clearing house up. Not only that when an employee terminates, you could more easily find someone who can step in. Right now, my billing people are worth their weight in gold because each insurer, each clearing house each contract is unique and we lose money when they make mistakes. it takes a 6-12 months to get a billing person really up to speed.

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Now on cost of healthcare, here's the thing ... requiring regulations on healthcare providers that would successfully bring the cost of healthcare down to a reasonable and sustainable level would mean removing a big chunk of their freedom to operate as private entities.
...
On top of that, providers would have to be required to accept the pricing index, and very few would want to. A federal agency telling a hospital they can only charge $250 to remove a boil on your butt isn't going to magically make the cost of supplies and utilities go down.

You make a good point. If we suceed in reducing the cost of healthcare, the providers / insurers are going to keep it... as long as everyone else is keeping it. However, even if they keep it and free market / competition principles don't reduce it, it ought to stabilize prices rather than the continuous escalation we see now...

Also, I don't think we need to reduce cost of healthcare by controlling insurers. We need to reduce the cost of healthcare by not subsidizing the cost of healthcare as much and as transparently. I liken it to what the credit card comapnies do, require retailers to not charge extra for using the card (even though it costs them 1-2-3% more to pay with credit) as a result, consumers adopted credit cards in droves. If the consumer doesn't know how much he is paying, how can he control costs?
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Re: What would you put in a healthcare reform bill

Postby Yayaril » Mon Dec 21, 2009 8:12 pm

The complete elimination of health insurance and total socialization of healthcare: to go into the healthcare industry would imply normal educational costs instead of the overbloated amounts present now, the physicians would be paid in line with other equally skilled workers instead of the overbloated amounts present now, and everyone would be able to be treated at no cost, as healthcare is a right.
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Re: What would you put in a healthcare reform bill

Postby kiryan » Mon Dec 21, 2009 9:19 pm

Other equally skilled workers? They go to school for 8 years + a 2-5 year residency to be a doctor, specialization requires additional 2-4 years of school + residency. Plus the medical board exams. So conservatively 10 years of school/residency which is still 20% more than your average PhD.

Who in your mind is "equally skilled"?

But I do agree that we can't have healthcare at these prices... at this level of quality. We've created a system today where too few people are able to get credentialed which helps drive the costs up due to the shortage of labor. I'm on board with lowering the standards which will lower the price and obviously the quality as well.

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If you want healthcare to be a right that the government must provide, then I think we need to see something that outlines what the citizen is obligated to do for the government / society. I mean thats Obama's problem with the constitution, it only outlines what government can't do, doesn't say a lick about what the government must do. We have a bill of rights, maybe we need a bill of responsibilities too and you can be expelled from citzenship if you don't meet your obligations.
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Re: What would you put in a healthcare reform bill

Postby Ashiwi » Fri Dec 25, 2009 3:21 pm

Oooooh, also drop in there a slight reduction in premiums or tiny tax incentive for those who register with a national organ donor service.

People probably don't realize how much it costs us to offer extended medical care to those who are waiting on a transplant donor. A reduction in time spent on that list would save the medical system a bundle.
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Re: What would you put in a healthcare reform bill

Postby kiryan » Wed Dec 30, 2009 5:50 pm

Thats a good idea, but on the other hand, the transplants are ridiculously expensive too... so how much money do you save shortening the time before transplant vs all the drugs you need after transplant to keep the body from rejecting the organ?

If you just wanted to save money on transplants, maybe we should ship all transplant operations to India where they do it for 10% of the cost we do it here in the USA. $70k vs $700k?

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some food for thought. basically, USA spends more on healthcare and has a lower life expectancy because we engage in unhealthy behaviors.

http://www.cnn.com/2009/OPINION/12/28/f ... index.html
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Re: What would you put in a healthcare reform bill

Postby Delmair Aamoren » Fri Jan 01, 2010 3:27 pm

kiryan wrote:Create and fund "free" government schools to train doctors and nurses. Do it in the military if you need to.
Reduce the difficulty of completing medical training by 33% until we have enough trained and certified professionals in the work force then ratchet them back up.


A lot of your points make sense. Basing the training in the military isn't a bad idea either. This last little bit quoted above is absolute shite. NEVER should we decrease the standards of ANY education, especially when healthcare is involved. The education for RN is not difficult. The education for MD is quite time consuming, but the issue isn't the education requried. It ties into a lot of the other points you've listed including malpractice insurance, etc. If anything, in the short-term, provide signing bonuses for people in these jobs, and perhaps some reward/motivation for more Physician Assistant jobs. Physician Assistants are educated enough to run most clinics. They do so under a different MD's license, but are a more cost-effective alternative.

Paramedics/RNs/EMT's/CNA's etc. are all plenty uneducated. Trust me. I'm one of them. If i had to work with someone who was a product of a LOWER education standard, i'd probably pull my hair out. (which would save money on haircuts, but sooo not the point)....
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Re: What would you put in a healthcare reform bill

Postby kiryan » Fri Jan 01, 2010 10:03 pm

While I won't disagree with you that there are stupid people in some of these positions, there is a shortage of healthcare workers that must be addressed if prices can come down. Nationally, they have been tlaking about a shortage of nurses for a good 15 years. Doctors for at least 10. The certification / education programs in place today do not come any where close to meeting the current let alone future needs.

Yes there will be some tradeoffs, but there are tradeoffs already... in cost, in access to doctors that is getting worse every day. Do you really need to go to 4 years of nursing school to learn how to administer a shot or check meds? Wipe an ass? do rounds? Do you really need your podiatrist (foot doctor) to have gone to have invested 15 years in school before starting to work? Does your doctor really need to have worked a 40 hours shift to prove something during his residency? Why can't we have someone go to school (or intern at a doctors office) for 4 years and learn pretty much everything they need to know about general family practice? They may not recognize some rare disease, or have seen that 1 in 100k scenario... but do they really need to? Why do they need 10+ years of certification before they can practice basic medicine?

PAs and LPNs are a good idea, but the reality has fallen far short of expectations. They bill at a higher rate than nurses, and often refer you to specialists or the doctor. They can't do nearly enough, because doctors are worried about losing clout. They are great when you have a cold, you can pay $75 for an office visit instead of $95 to see the doctor, but its hardly cost effective when you pay them $75 and then they refer you to a $150 specialist. LPNs that can write presciptions are pretty useful.

I'm not saying we can never go back to the more rigorous standards, but I'm saying reduce the requirements right now until the labor shortage goes away. Doctors and nurses can already charge whatever they want and its getting worse. I know dozens of regular nurses who make 100k a year with overtime (not including benefits).

Oh and btw, electroic health records do not make doctors more efficient. They make them less efficient. It makes their offices more efficient and patients have better records, but the doctors themselves literally see fewer patients. So toss that in to the already looming doctor shortage.

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