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Saturday, May 27, 2017

Sanity In Healthcare

Versus Raming a 100 million ton square peg into a 100 foot diameter hole

Actually Restoring Sanity to Health Care

In an Article in Linkedin:

Ten Free Market Commandments Restoring Financial Sanity in HealthCare, by Dr. Robert Nelson

Dr. Nelson tries to make the case for using "free market principles" to reform health care. In so doing he makes points that a little rational thought will demonstrate make no sense. But they do make the case for a single payer system and socialized medicine. This is because the Healthcare System is:

"a proper social function, which should be controlled and managed by and for the whole people concerned, through their proper governmental, local, state or national, as may be."Constitution

Sovereignty of Individuals within Society

    Nelson Asserts an almost blasphemous claim that people should:

  1. Believe in the sovereignty and good judgment of the individual patient to seek care as they see fit, at a transparent price known in advance of services and in the absence of insurance network constraints.
  2. Actuarial Calculations

    "The absence of 'Insurance Network Contraints'" really means pay as you go medicine. Because any other system for paying doctors will have actuarial calculations that consider the financial health and cost of medicine, which is what "insurance network constraints" are. But do the actuarial concerns vanish if one tries to fit health care into a market? No!

    Market Failure!

    Providers must be paid, whether it is by patients or out of a common fund. The only difference between an insurance common fund and government is that an insurance company can include overhead and administrative costs (including CEO and Investor pay "Profit") in their calculations. While Government run plans also have access to tax money. Both have to charge fees or taxes to pay providers and material support for their work.

    A pay as you go system simply doesn't do the calculations, and therefore cannot meet the needs "Market Failure" of wide swaths of the public. Under a purely private system things revert to the situation in the middle ages where only economic royalty could afford doctors. Doctors aren't going to work for donations of pigs or chickens. Even if economic inequality is evened out (say through a universal basic income), the resources needed for healthcare vary from day to day, person to person and along a lifetime of physical change. It is absurd to think that the average person can pay out of pocket for, say cancer treatment. A pay as you go rations healthcare by income and people die. The Term for such a system is not a "free market" but market failure.

    Argument for Single Payer as "unencumbering Doctors"

    Nelson is right to assert that we should:

  3. Understand that quality medical care starts with an unencumbered Doctor-Patient relationship.
  4. Therefore there is no getting around the need for

    Essentially the principle of subsidarity should apply to health care delivery. Administrators can administrate the money, guide difficult decision making and ensure that resources and personnel are balanced to the demand. But when they dictate they usually get more in the way of effective health care delivery than help it. Anyone designing a good system knows that it require republican and commonwealth principles at the local level, freeing doctor and patient to do what is necessary.

    Nelson next asserts that we should:

  5. Acknowledge that a doctor serves their patient’s needs better if they work directly for the patient, and not within the constraints, mandates or barriers of a provider contract with a third party.
  6. Those constraints include limited resources. Which is why funding healthcare should be funded, controlled and managed for the "whole people concerned" as healthcare is the ultimate in a "necessary Social Function." However, delivery and rationing should never be centralized except as a general governing function. Doctors need to be able to function without the greed of a profit motive or the fear of loss.

    Freedom means liberating the mission

  7. Realize that only by creating free-agents of both physicians/providers and patients/employers will we bring together the stakeholders for a meaningful exchange of value, thus substantially lowering medical costs in the outpatient arena.
  8. Most doctors with integrity don't even want to get rich off of other folks suffering. They want to be able to practice their specialty and be rewarded both spiritually and materially for the public good and services they provide. A proper system ensures that there are sufficient doctors for each location and specialty and a reserve of providers for emergencies and specialized treatment. This means training doctors and providers, having sufficient numbers of schools and entry level jobs and we probably should use a reserve health system to ensure we have emergency providers in some abundance to surge during disasters. In essence healthcare is a militia type function. It is necessary everywhere, but not always at a particular moment.

    Paying Doctors Salaries

    Nelson next admits that Insurance is not a market system:

  9. Acknowledge that the main driver of health care costs in the outpatient arena is not malpractice costs or high-tech treatments, but rather expensive third party prepaid policies that utilize complex, non-transparent billing protocols resulting in massive price insensitivity and over-utilization, paying “first dollar” benefits for virtually any physician interaction, regardless of how minor.
  10. Our Current system tends to be a piecework system in a world where factories and automation have made piecework pay absurd. Paying doctors by the procedure guarancies that at least some will game the system unnecessarily and others will game it by necessity for survival. We have to pay providers reasonable salaries and not let material providers, administrative bodies and institutions be forced into weird billing. This is another argument for single payer.

    This also points out the insanity of treating medicine as a market. Nobody bargains over how much a bandage costs. We have limited choice in where we go when we suffer trauma. Treating emergency care as a market is murder to the injured. Forcing people to drive themselves to the emergency room makes no sense. All treating healthcare as a market does is to encourage more middlemen, more inflated costs on necessary and unavoidable services and goods. And treating it as a market encourages privateering in usury in finance and and monopolization and price gauging on vital medicinal goods. Healthcare is not a free market because most ill are not free to say no (unless dying is the only choice) or to choose to go somewhere else when they are ill.

    Rationing versus Innovation and sustenance

    Nelson next states:

  11. Realize that in order to gain control of spiraling medical costs, health plan “coverage” needs to move towards a true “insurance” policy such that it pays out fewer claims that are higher in price, that we otherwise couldn’t afford on our own.
  12. The healthcare privateers would solve this problem by price rationing. A better approach is to use a mix of specialized providers at central locations, with widely dispersed and available preventative, general and available clinics and offices in every community. Again a Reserve model works here. University hospitals in major cities and capitals can also co-locate extreme trauma care, while reserve hospitals can function as clinics in ordinary conditions. There is a national interest in having surge capabilities. Moreover, using a reserve system allows people to be trained under universal "discipline prescribed by congress" and payback some of the expenses of their training by serving in under-served communities for a time.

    Networking Versus Centralization, Single Payer

    Nelson's Seventh point also demands Single Payer:

  13. Embrace the concept that health insurance works best when it is portable, personal, private and not linked to employment, nor zoned by networks. This approach would allow insurance policies to be tailored to individual needs, cut down on the number of uninsured due to job changes and other life events, thus obviating the need for expensive COBRA coverage.
  14. This argues for a National, even an International system, with national standards for training, Best Practices commissions to learn from mistakes and failure, and Single Payer for paying for it, and a completely portable private medical record for tracking a person's health needs, case and usage. Point 8 also argues for single payer:

  15. Understand that the true costs of directly contracted -directly paid medical care is much lower than that reflected by the claims-based cost of a co-pay based health insurance policies offered in the workplace today.
  16. Point 8 makes sense from the Point of View of Doctors and wealthy patients. Not so much from the Point of View of the ordinary patient. However, if Doctors can bill a single payer system, or better yet, be compensated with a salary. the effect would be the same. As mentioned above a purely patient paid system discriminates against the working poor.

    And also argues for single payer.

    Pay Doctors rationally

  17. Embrace the economic realization that only by creating free agent of physicians and patients AND using advanced pricing instead of Fee-for-coding, will economic forces send proper signals between buyers and sellers regarding price, thus determining the fair market value of routine non-emergent medical services.
  18. Coding has some actuarial, statistical, epidemiological purposes. But we all realize how much of a pain it is to doctors and an administrative burden.

    Health Awareness Important

    I think everyone agrees with #10 at least in principle.

  19. Empower the idea that better informed consumers make better patients and unrestricted patients make better consumers.
Related Posts:
Georgist Constituion
Privateering in Healthcare
We can Afford to Cover Everyone/dd>
When Market Solutions are Absurd
What Hillary Actually said

There are more, but that is enough for now

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