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[culture] A small Gedankenexperiment on healthcare - Lakeshore — LiveJournal
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Jay Lake
Date: 2012-12-16 07:20
Subject: [culture] A small Gedankenexperiment on healthcare
Security: Public
Tags:child, culture, health, healthcare, personal
My experience of being deeply enmeshed in the healthcare system is that a majority of my non-billing paperwork (and a meaningful percentage of my billing paperwork) is intended to ensure that I am qualified to receive certain benefits, and to check my continuing eligibility. Another way to put this is that a majority of the patient-facing overhead of healthcare delivery costs, meaning costs exclusive of actual medical expenses, is about compliance.

A simpler way to put this is that we spend a lot of money making sure only those judged deserving are helped.

From my perspective, the only three things I've done in my life that were more paperwork intensive than being a patient in the American healthcare system were to apply for a security clearance, buy real estate, and adopt [info]the_child. I did all of those things successfully while in good health and of sound mind.

Being very ill in America invokes a messy, complex, internally inconsistent system that requires a lot of focus and precision at a time in most people's lives when they are least equipped to provide those things. If indeed, ever they were. Not everyone is good at paperwork. And this is me, who is not dealing with public benefits and all their myriad oversight requirements, but rather a relatively sane and generous employer and employer-sponsored private benefits plan.

So let's assume a certain number of claimants are fraudulent. That's true in every walk of life with every kind of benefit — someone will always be trying to figure out a way to get something for nothing.

What would happen if we simply let those people into the system? If, instead of spending money on compliance we spent that same money on delivery? Would net costs go up or down?

We'd certainly have a system that is much kinder and more supportive to the overwhelming majority of users, its legitimate patients. Instead of punishing the users along with the fraudsters, let's keep things simple for the people in most desperate need.

Would that cost more or less? I have no idea. But it would be the mark of a compassionate society that values life, liberty and the pursuit of happiness over punishing the undeserving and deserving alike.

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User: nicosian
Date: 2012-12-16 15:30 (UTC)
Subject: (no subject)
I seem to have read somewhere so very recently that costs of healthcare weren't so much "consumer demand" as over billing on services patients never see.

But its a ludicrous thing to have such gatekeepers on care, its unfathomable to me, in the middle of my own adventure, I don't have to justify, with my doc, to anyone, any decision we've made. He prescribes, I receive, end stop.

We do have frequent fliers and malingerers in ours but your experiment...to us its not such an extensive concern we spend millions and billions on. Its but a blip in the system.

( That said, the odds of people going in for scans for larfs and because they're FREE!" is pretty remote, really.)
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houseboatonstyx: smaller-healing-buddha
User: houseboatonstyx
Date: 2012-12-17 01:59 (UTC)
Subject: (no subject)
Well, not larfs exactly, but there can be a certain hypochondriac demand. Otoh, extensive blood tests and some scans are getting cheaper and are now offered without prescription by small high-tech companies unconnected with the medical establishment. One pharmacy even advertises free bone density scanning.
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User: nicosian
Date: 2012-12-17 02:40 (UTC)
Subject: (no subject)
my point is the demand isn't SO high via hypochondriacs and "worried wells" that we need a third party gatekeeper to access.

Doctors can, and do make the call, and on thinking, I would suspect this is where people get the white hot rages at being denied something by a doctor in our system as some kind of evil government plot.

i'm in canada, so the rules on what private clinics offer is different, but I am not complaining about 9 day waits for MRI for non-really emergent cases as my husband's was.
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Kevin Standlee: Not Sensible
User: kevin_standlee
Date: 2012-12-16 15:35 (UTC)
Subject: (no subject)
Keyword:Not Sensible
Many years ago, I worked for a company that was the contractor that actually processed Medicare claims. Our team was evaluating a new claims-processing system. When we came to the milestone go/no-go date, our team recommended "no go" because of all of the bugs in the system. Our higher management overruled us and issued a "go" order. Our subcontractor turned on the system, and as we predicted, we stopped paying claims. All of them. Nothing would go through the system. Chaos ensued, of course. The Healthcare Financing Administration (the government agency that runs Medicare and thus was the entity to whom we were contracted) was livid, and beneficiaries and healthcare providers furious.

After a few days of this, and a conclusion that, having moved forward, we couldn't go back to the old system that worked, management told us to turn every single medical-necessity edit (the compliance stuff you're talking about) off. For about a month, had you known about it, you could have submitted anything and we would have paid it. Tolerating the percentage of invalid claims was cheaper than the penalties we were paying for not paying anyone at all.

But getting back to your question: I expect that there's a strong streak in this country of people who are much happier spending more resources keeping the "undeserving" out than we save in doing so. For instance, think of proof-of-payment transit systems like Portland's Tri-Met light rail, where, as you know, there are no barriers to entry and you only show a ticket upon request, although there are hefty fines for failing to have a ticket when requested. I've heard many people complaining that such systems should have complicated and expensive fare-gate systems (like BART or the New York subway) even if doing so would cost more to implement and maintain than POP. It's not the revenue protection (even though most people frame it that way) — it's the "nobody must every get away with anything, no matter how much we spend to prevent it" mindset.

With SF conventions, I've pointed out that it's pointless to spend more resources on anti-fraud measures (complicated membership badges) than you can reasonably expect to save by doing so. However, I still encounter people who think that no amount is too large as long as you prevent even one person from forging a membership badge. Better to spend $20,000 on complicated anti-fraud measures than to have a single $200 fraudulent Worldcon membership badge get into the convention.

All of these things, and the mean spirited nature behind them, are reasons I think we'll not be able to get away from spending so many resources on medical-necessity paperwork such as you describe.
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User: cissa
Date: 2012-12-21 22:23 (UTC)
Subject: (no subject)
I read someplace, a few years ago, that about 2/3rds of the money spent on "welfare" for the poor actually goes to the middle-class gatekeepers on the system.
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User: threeoutside
Date: 2012-12-16 16:35 (UTC)
Subject: (no subject)
Partially maybe it's a selfish, punishing desire to make sure no one gets anything they're not entitled to, but mostly, we must remember, the insurance business is a business and their first concern is NOT the patient. It's the patient's money. And how much money they can keep from spending on the patient. If it seems inhuman, that's because it is.
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Jenny Rae Rappaport
User: eiriene
Date: 2012-12-16 16:37 (UTC)
Subject: (no subject)
The best part is when the people in charge of the paperwork screw up and enter in the wrong billing code. And then you spend years chasing them down, avoiding idiot credit collection people, until you get them to correct the billing error. (Oh, I'm not bitter about my experience with routine bloodwork at Quest getting wrongly entered into the system. Not bitter at all.)
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User: voidampersand
Date: 2012-12-16 17:00 (UTC)
Subject: (no subject)
If someone fraudulently claims to have cancer and asks for surgery and chemotherapy, I cannot imagine any worse punishment than saying "okay, here you go."
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User: mmegaera
Date: 2012-12-17 02:58 (UTC)
Subject: (no subject)
Oh, dear. I shouldn't be laughing at this, but I am. Thank you.
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triskelmoon: Mackie and Me
User: triskelmoon
Date: 2012-12-16 18:51 (UTC)
Subject: (no subject)
Keyword:Mackie and Me
Speaking as someone who has worked at a major medical facility for over a decade: from the medical delivery side, costs would go down. We have huge labor costs that are just people who need to navigate the multiple payors, what they cover, and how much. This is aside from the write offs due to each major medical insurance having a different contract with us (they each get their own "deal" on pricing). And this is aside from the administrative costs and profits the medical insurance companies charge (reap).

I've been following pnhp.org for years and wish it could become a reality. I truly believe that health insurance profits are blood money.
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User: martianmooncrab
Date: 2012-12-16 21:20 (UTC)
Subject: (no subject)
I got thrown into the deep end of that system when I was helping my cousin who had the stroke. It was a maze and paperwork horror at times. They wanted all sorts of documentation and personal details, copies of forms, ID, employment history... like you had cheated Social Security out of money if you had worked and FITW hadnt been paid into.. the only thing they didnt ask for was a blood sample, but they did request access to your health records.
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User: joycemocha
Date: 2012-12-16 23:00 (UTC)
Subject: (no subject)
We are negotiating the careful dance of extending health care for a chronically ill son who's aging off of our insurance.

It's rather like what I imagine the mating dance of porcupines to be. And contemplating the different potential rates....shudder.
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User: a_cubed
Date: 2012-12-17 00:14 (UTC)
Subject: (no subject)
So far as I can tell, there is no single way in which the US medical system is actually optimal on any measure except perhaps the profits sucked out of the system by some protection gangs, sorry health insurance companies. At the Security and Human Behavior conference last year there was a presentation on fraud in US healthcare. I asked the question of the presenter that I could tell was in the minds of every non-US audience member: "How much of this fraud is due to the broken US coverage system?" i.e. people getting treatment that they don't have coverage for? Sure, there's also a lot of unnecessary care, actual un-performed care, also in the system and in fact on systematic levels it's probably the single largest part. But again, that comes down to having profit-driven health-care providers instead of non-profit or pubic sector ones.
The UK system does have fraud, but it's estimated to be much lower and is mostly people from overseas travelling to the UK to get treatment (yes, the NHS does provide better treatment than many other places in the world, though it has its flaws).
I'm not sure how much fraud there is in the Japanese system. I suspect no one looks at it very hard, because that's the Japanese way. Perhaps the current financial problems might make them consider what systematic frauds are happening.
Last rambling point - I'm rather reminded of the "voter fraud" issue here as well. The "cure" is worse than the "disease" unless you happen to be the beneficiary of the concomitant "disease" (the GOP for voter fraud and the insurance protection racketeers for medical insurance).
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User: voidampersand
Date: 2012-12-17 03:38 (UTC)
Subject: (no subject)
I don't think it's protection racketeering, but it's very close. The US health insurance racket is corrupt, and people are motivated to pay up through fear. But that's as close as it gets. In a pure protection racket, you pay the racketeers to be protected from the racketeers. In insurance, you pay the insurer to help you if and when you are in need. If you stop paying for health insurance, the insurance company does not send agents over to beat you up. Partly they don't have to, but also they're not that sort. They are petty bureaucrats who have inserted themselves unnecessarily into every medical transaction, sucking money out of the system and causing endless confusion and suffering. But they're not thugs. And I don't think we can get rid of them by calling them things that they aren't, quite.
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User: del_c
Date: 2012-12-17 12:03 (UTC)
Subject: (no subject)
It can't be said often enough, we don't have *any* of this in other countries. Reading these accounts from America is like a look into some fictional dystopia, or the nastier periods of history.
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