Respectful Insolence

And now for something completely different…

Unfortunately, it’s all too easy to find new woo-filled claims or dangerous, evidence-lacking trends to write about. Heck, I did it just last week. Examining certain other health-related issues from a science-based perspective is more difficult, but I feel obligated to do it from time to time, not just for a change of pace but to stimulate the synapses and educate myself—and, I hope, you as well—about areas outside of my usual expertise. As much as I enjoy bringing a science-based perspective to topics like cancer quackery, vaccines, and all manner of alternative medicine (most often also known as quackery), it’s good to branch out from time to time.

That doesn’t mean I don’t still spend a lot of time writing about the scientific basis of medicine, clinical trials, what is and isn’t quackery, and how “complementary and alternative medicine” (CAM) subverts the scientific basis of medicine. However, the idea of science-based medicine (SBM) goes far beyond just that. At least I think of it this way. That’s why I’ve looked at issues that go more to the heart of health policy, which should be based on sound science and evidence. That evidence might take different forms than it does for determining, for example, whether Medicaid results in better health outcomes and by how much health insurance does the same. As is the case with policy issues and economics, conclusions are muddled and messy. The error bars are huge, and the number of potential confounders even huger.

One of the most vexing problems confronting the US health care system is the issue of cost. As has been documented in many places, the US health care system spends more per capita than pretty much anywhere else in the world for outcomes that are, at best, equivalent to those of the health care systems of other industrialized countries. How to fix that problem and “bend the cost curve” downward is the single biggest problem our current health care system faces. The Affordable Care Act (ACA, a.k.a. “Obamacare”) tries to make steps in that direction by emphasizing comparative effectiveness research and finding ways to encourage the use of less expensive treatments that are equally effective and to discourage the use of unnecessary procedures. This is a problem that long predates the ACA.

It’s also a very difficult, seemingly-intractable problem. Part of what contributes to it is a host of practices that are not supported by evidence or science but that continue. A classic example, of course, is the prescribing of antibiotics for viral illnesses. Patients, under the mistaken impression that it will help them, demand it, and physicians, even though they (usually) know better, are all too often willing to acquiesce to their patients’ requests because it’s far easier and takes less time to acquiesce than it does to explain why antibiotics are not necessary. Nor are doctors entirely blameless in this, as we all-too-often hate giving the impression of “doing nothing.”

So what’s the answer? According to this story by Sharon Begley entitled “In healthcare experiment, patients pay more for ‘bad’ medicine” that I saw late last week, it might be behavioral modification:

When Tanner Martin, 17, developed excruciating back pain last year, he was sure he needed an X-ray to find out what was wrong. So was his mother, who worried that the pain might indicate a serious injury that could cause permanent disability.

But Konnie Martin was no ordinary parent. As chief executive officer of San Luis Valley Regional Medical Center in Alamosa, Colorado, she is at the center of an experiment, known as value-based insurance, that could transform American healthcare.

One of the central features of a value-based system is a financial “stick.” If patients insist on medical procedures that science shows to be ineffective or unnecessary, they’ll have to pay for all or most of the cost.

In Tanner’s case, when he and his mother went to the medical center, they were invited to watch a short video first. The best approach to back pain like Tanner’s, it explained, is stretching, strength-building and physical therapy; X-rays and MRIs, according to rigorous studies, are unlikely to make a difference. If they insisted on the X-ray, they would have to pay $300 on top of the basic cost.

They passed on the imaging, knowing they could change their minds if Tanner’s condition worsened. After three weeks of therapy, his back was as good as new.

As you can see from this anecdote that introduces the story and the problem, the basic idea is to make patients pay more if they insist on tests or treatments that, according to science and evidence, won’t help them. The concept seems sound on the surface, but is it? And what is the evidence? The clinical encounter described above came about as a part of a two year experiment by San Luis Valley in what is commonly referred to as “value-based health insurance” or “value-based health care.” It’s nothing new, but with the advent of health insurance and health care reform, health policy wonks have been taking more interest in it.

Not too long ago, I wrote about an initiative by the American Board of Internal Medicine Foundation (ABIM) known as Choosing Wisely. It is an initiative in which a challenge, if you will, was issued to professional societies to identify five practices in their specialties that are ineffective and add no value to patient care. As I described, in oncology some of those practices involve imaging for extent of disease in breast cancer (which is very commonly done but has never been shown to improve patient outcomes) and a variety of other practices that are still common in oncology and oncologic surgery. Value-based health care sounds to me like Choosing Wisely on steroids. It could be the logical next step in the progression. Obviously, if a treatment or diagnostic modality has not been validated by science and clinical trials, it doesn’t make sense to pay for it.

The evidence base for value-based health insurance, however, is rather sparse. Begley notes that the San Luis Valley Health experiment only involves 725 covered members and dependents. That’s not an unreasonable number for a pilot experiment, but it’s far from enough to be able to tell whether value-based health care can deliver on its promises. The experiment is going to wrap up at the end of this year, and the data are to be analyzed in 2014. However, at most what will be able to be determined is whether costs are decreased.

One of the experts interviewed by Begley for the piece was Dr. Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design and a professor of internal medicine. Since the University of Michigan is just up the road from where I work (well, if you consider 45 miles or so “just up the road”), I figured I’d peruse its website and see what it says about value-based insurance:

The basic V-BID premise is to align patients’ out-of-pocket costs, such as copays and premiums, with the value of health services. This approach to designing benefit plans recognizes that different health services have different levels of value. By reducing barriers to high-value treatments (through lower costs to patients) and discouraging low-value treatments (through higher costs to patients), these plans can achieve improved health outcomes at any level of health care expenditure. Studies show that when barriers are reduced, significant increases in patient compliance with recommended treatments and potential cost savings result.

Note that the concept is not just to penalize care that is not scientifically supported but to reward care that is by decreasing barriers to receiving it. For instance, this is one of the studies cited by the University of Michigan. Basically it looked at the effect of an insurance plan reducing copayments for five chronic medication classes, including: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs); beta-blockers for hypertension and heart disease; diabetes medications (such as oral therapies and insulin); HMG-CoA reductase inhibitors (statins); and inhaled corticosteroids (such as Advair for COPD and other chronic pulmonary conditions). Copayment rates for generic medications were reduced from $5 to zero. Copays for brand-name drugs were lowered 50 percent (from $25 to $12.50 for preferred drugs and from $45 to $22.50 for nonpreferred drugs). All patients in the treatment firm (treatment and control groups were organized by company, not by individual patient) who were already taking any of the intervention medications without a contraindication were eligible for the copay reduction, beginning with their next prescription fill. Copay relief was also available for those who were not taking the medication if they were identified by the clinical alert system as patients who would benefit from the medication.

The study design was temporal, with results examined pre- and post-intervention. For each drug class, people were selected for the sample in a given year if they used the medication within three months of the study year and didn’t have a contraindication for its use or if they were identified as having a clinical indication for the medication but didn’t use it within the previous six months. The overall results were that, compared to another health plan, participants in the plan that decreased its copays for these medications demonstrated reduced nonadherance by as much as 7-14%. Obviously, there are a lot of shortcomings to this study, such as the question of whether the control group is adequate, but it does indicate that there might be merit to this approach. It also suggests that “value-based” health insurance might actually not be the best way to control costs, because lowering the copays actually increases cost, at least in the short term. Whether that short-term increased cost is later compensated for by decreased costs caring for complications of these chronic diseases over the long haul is something that is yet to be determined.

Indeed, according to this recent review, cost savings from value-based insurance designs have been elusive:

While these copay changes to incentivize the use of certain technologies show improvement in some process indicators, they have not yet achieved cost savings.21 For example, the same Blue Cross Blue Shield study found no cost savings.19 Another recent article by Choudhry et al (2011) found no significant difference in costs between a group with no copay for cardiovascular drugs and a group with regular cost sharing.22 The lack of significant cost savings may be due to the short follow-up times in these studies —usually 1 year. More research is needed in the area of cost savings of incentivizing the use of certain services. This will become especially important as the ACA has also required that insurers provide all the USPSTF recommendations free of charge.

In lieu of long-term follow-up, modeling suggests some long-term savings, but these analyses have often focused on raising copays for “low-value” services. For example, the 3 main treatments for prostate cancer vary greatly in their average costs with no evidence that the more expensive treatments result in better outcomes. A radical prostatectomy costs $7,300, brachytherapy costs $19,000, and radiation therapy costs $46,000 on average. Newer forms of radiation treatment can cost close to $100,000 per case, and have not been shown to have any clinical advantages over any of these less expensive options, including watchful waiting. A simple VBID policy would be to modestly increase the cost sharing for these services to encourage more use of the cheapest and equally effective prostatectomy. The authors of the same prostate treatment study estimate $1.7 to $3 billion could be saved directing patients toward the lower-cost treatments.

This suggests another issue. Surgery might be the cheapest treatment for prostate cancer (yes, contrary to what many believe, surgery is often the least expensive option for treating certain diseases), but it is the most invasive and likely to have the most impact on quality of life, with its known complications of retrograde ejaculation and erectile dysfunction. True, radical prostatectomy costs even more if, as is all the rage these days, the da Vinci robot is used. It’s always better with robots, isn’t it? I’m sure Sheldon Cooper would agree—except that it isn’t always. There’s no compelling evidence that robotic prostatectomy results in better outcomes than current laparoscopic prostatectomy. Add to that the problem of overdiagnosis and overtreatment of prostate cancer, which leads to the question of which prostate cancers even need to be treated and even what the very definition of “cancer” should be. The new focus on cost is going to force medicine very quickly to decide how much it values quality of life, because treatments that are effective at eradicating the disease but less so at producing high quality of life are often cheaper.

This is just one example, of course. There are thousands of examples, ranging from common mild conditions to common serious conditions to uncommon conditions. One area, however, where such initiatives might bear fruit and change behavior is by simply hitting doctors and patients over the head with data indicating which treatments do and do not have science and clinical evidence behind them:

The very idea that some diagnostic tests and treatments might not help patients comes as a shock to many Americans.

The Choosing Wisely message is difficult to convey to the many patients who “think that when it comes to medical care newer is better and more is better,” said Dr. Yul Ejnes of Brown University’s Alpert Medical School. “So when patients have more skin in the game (in terms of cost), they’re more likely to ask, do I really need this?”

San Luis Valley Health is self-insured, and the experiment involves only its 725 covered employees and dependents.

The experiment puts medical services in green and red “buckets.” Green is for procedures that should be encouraged because they are cheap and effective, like vaccines. Red is for expensive ones that, research shows, are usually unnecessary, ineffective or even harmful. They include endoscopy for heartburn, surgery for enlarged prostate and the imaging tests that Konnie Martin’s son declined.

Patients (and, unfortunately, a lot of doctors) have a tendency to assume that more care must be better, when in fact often it is not. We here at SBM have discussed how and for what diseases that is often the case many times in the past. On the other hand, policy wonks seem to make a related assumption, namely that “preventative” care will save money, an assumption for which the evidence is at best mixed. The reason is obvious. Preventative medicine costs more and results in more costs treating the diseases and conditions that it uncovers. However, it is not entirely clear that it saves money in the long run through earlier treatment and intervention to prevent the complications of chronic diseases and diagnoses other diseases at an earlier point in their courses. As value-based insurance advocates admit:

It has that potential, although whether the kind of patient targeting VBID proposes saves in long-term costs remains an open question. “Does it make good business sense?” asks Chernew. “It depends on how it is designed. It certainly can. Lowering copayments itself does not necessarily save money, but the programs are designed to make people healthier. We do know that the long-term benefit still requires a comprehensive look.”

Notwithstanding a lack — so far — in established long-term savings, the concept is most certainly gaining favor with large employers, including several members of the National Business Coalition on Health, who are pushing for VBID when they solicit vendors.

That is the crux of the issue, as I’ve mentioned. Will the short term investment yield long term savings? No one knows, and the evidence is mighty sparse. However, it’s another truism in medicine that it’s not possible to wait for perfect data. We have to make the best judgments we can with the science and data that exist now, hopefully making adjustments as new data and science are reported.

Another issue that comes up is the perception of fairness. Communication is the hard part. Consumers love carrots like reduced copays, but they aren’t particularly fond of sticks (like making them pay much of the cost of “unnecessary” tests and treatments out of pocket in addition to their existing health insurance premiums), so to speak, which are perceived as punitive, even if employed in the service of “encouraging” patients and practitioners to use more science- and evidence-based medicine and to stop using medicine that is not supported by science. Advocates of value-based systems claim that they don’t intend to penalize patients for treatments in which the evidence is conflicting, or, as it was stated in Begley’s article, “subject to debate.” However, this question really does bring up an incredibly dicey issue: How much evidence is “enough” to demonstrate that a test or treatment is not of value and therefore should be subject to financial disincentives? Doctors will disagree. If a physician tells a patient that he really needs a treatment, and that treatment is one that is not covered, the patient will feel abused and betrayed, as will the doctor. The example above, in which the patient is offered education, might be the way to handle this problem, but it requires physician buy-in.

More and more, I find myself having to consider issues that I never had to consider much before, such as quality of medical care and cost of services. I never really saw myself ever becoming a health policy wonk or a quality of care analyst, but increasingly such skillsets are becoming necessary to my career. I’ve had to learn, and the curve is steep. It’s a fascinating and ridiculously complex area that makes some of my old lab experiments seem very straightforward in comparison. (I am, after all, used to being able to control most variables.) However, it is every bit as much a part of SBM as clinical trials and bench research. We as SBM advocates would do well not to neglect it, because it really is where the “rubber meets the road.”

Comments

  1. #1 Road Less Traveled to MD
    USA
    December 27, 2013

    I’m a second year medical student in the USA and was surprised you failed to mention any of the type of diagnostics physicians order just to cya. Liability. Fear of lawsuits. Retribution. These play an untold burden on medical costs as compared to 50 years ago. Defensive medicine is a sad state of affairs in a profession that takes an oath to “first do no harm “. Writing antiviral Rx medications for bacterial infections are minuscule in costs of care versus ordering CT Scans and MRI that are strictly cya.

  2. #2 Chris Hickie
    December 27, 2013

    If both patients and physicians realize they are being steered (even if science-based) by insurers towards specific treatments and medicines, they will feel controlled by insurers–even if those medicines and treatments actually are the best science-based choice. This has always been the problem with third party payers–they will say they are not practicing medicine, but when we rely on them to finance it, they do have an impact on our choice of treatment. Also, doctors are under increasing pressure to see more patients in less time–in part to support the increasing numbers of staff it takes to keep a clinic financially afloat among a rising ocean of regulations as we try to prove “meaningful use” to insurers (usually medicare/medicaid). Proper patient education can’t happen in a 5-minute sick visit, and that is why I think sometimes an unnecessary test or medicine is prescribed–to let the patient feel like we at least did something for them. Finally, there are some people who just won’t take their medicine no matter how much you talk to them. There’s no way to fix that short of forcing them to do so (which while common in pediatrics for obvious reasons, isn’t something easy to do for adults).

    Is anything more about this actually being taught to new doctors-to-be in medical school today?

  3. #3 Marry Me, Mindy
    December 27, 2013

    Does the cost of surgery include the cost of complications for those patients that have them?

    Sure, the cost of the outpatient surgery is $7500, but if 1% have complications that lead to an extra cost of $50K, that’s another $500.

    Still not huge, but that’s a made up number.

  4. #4 Captain A
    A Purgatory called the American Health Care system
    December 27, 2013

    If the Payer/Insurer has a financial incentive to declare a treatment unproven, or ineffective, or not indicated, then you can bet they will. In my experience the evidence bar very high indeed. Usually the bar is “FDA approved”.

    This high bar leads to some very silly denials. For example in my practice I routinely treat chronic idiopathic urticaria with double dose or even quadruple dose non-sedating antihistamines. Of course this is off label, and to be honest the evidence base for this approach is rather scanty. None-the less, this is standard and recommended second line therapy, as standard dose antihistamines having a long track record of success with treatment of hives, and high doses of non-sedating antihistamines are both very safe and very cheap. Alternative treatments have an even smaller database in trials and second and third line agents are either marginally effective (leukotriene antagonists, H2 blockers) or expensive and/or side effect troublemakers (prednisone, cyclosporin).

    And yet, it is not uncommon to receive a message in my inbox explaining that the insurer has denied my twice a day 12 cents/pill Loratadine 10 mg prescription because, thats right, it is off label. A prior Auth request usually takes care of it, but this kind of thing happens every day, and it costs the providers time and money, and a great deal of aggravation. Paradoxically, I could easily run a set of allergy tests to the tune of $800 or more, completely unnecessary, and they will happily reimburse that. For the record, I don’t do that, but I have seen numerous examples of doctors running oodles of unnecessary allergy tests.

    I really don’t have much hope that an external system of checks and controls will be able to reign in health care expenditures. The private health insurance industry has been trying and failing for 30 years. They are
    1) Too far away from the point of care
    2) Grossly lacking the knowledge base to make good judgements.
    3) Hopelessly conflicted from a financial standpoint, as the above case illustrates.

    Furthermore the delivery of most health care is far too complicated and nuanced to fit into some algorithm. I’ve been building algorithms for 20 years for the limited set of problems that I see as an allergist and I am continuously confronted with variables and scenarios that require novel solutions and approaches.

    Until the perversion of fee for service is removed from the equation, I don’t see any hope.

    Curt Watkins MD

  5. #5 lilady
    December 27, 2013

    @ Captain A: Isn’t Loratadine available as “Claritin”, an OTC medicine?

    My family and I have had a variety of drug reimbursement insurance plans and none of them ever provided coverage for drugs prescribed by physicians, which are available OTC.

  6. #6 mho
    December 27, 2013

    @lillady
    mine covers proton-pump inhibitors, even though they’re available OTC.
    Also, if a doctor prescribed vitamins, the cost was tax deductible, once the % of income threshold was crossed.

  7. #7 Captain A
    December 27, 2013

    @#5 Lilady

    You are correct. Loratadine is generic Claritin and I’ve seen generic OTC at the Dollar store for 10 cents a pill. You are also correct that most insurance plans will not cover it because it is OTC. Knowing this, if a patient has trouble coming up with the $4/month, I will sometimes write for prescription antihistamine Clarinex (desloratadine) instead so the patient doesnt have to pay out of pocket. This costs the insurer a LOT more. Law of unintended consequences in action.

    A few insurers have figured this out and will pay for selected OTC, for example PPIs as mho pointed out. . Another example is our state Medicaid will pay for Loratadine. So much for private companies being so much more efficient and nimble.

    C

  8. #8 Chris HIckie
    December 27, 2013

    You can get claritin for 4 cents a pill at costco. I have to be honest that I have a hard time believing someone can’t figure out how to come up with 4 cents a day.

  9. #9 Gemma
    UK
    December 27, 2013

    As an NHS employee in the UK, this subject seems a no brainer in principle but a nightmare in practice. If I go to the Dr here with a viral infection I get it diagnosed as such and told to go home and take fluids and rest. Posters are all over the waiting rooms telling me I’m wasting my time asking for antibiotics for flu because I won’t get them. It infuriates me that so many advertisements in the US tell us to ‘ask your dr for drug X’. In Britain it’s accepted that we’re not all Doctors and that they know what they’re doing better than their patients. I can’t imagine working in a healthcare system where my patients demand something entirely inappropriate and/or expensive and are in a position to veto my professional advice through bullying tactics and effectively self-prescribe from their TV ad-break educated opinion. I feel for you on that side of the pond… even the most right-wing political groups in the UK believe in social medicine but I’ve yet to grasp the communist fear mongering of it in the US.

  10. #10 mho
    December 27, 2013

    It isn’t just the .04 per day. Its also the problem of getting to a Costco, when an ordinary phar. may be 3 blocks away. (I don’t know if the mail order)
    While the patient should be paying for OTC drugs that are for occasional use, I personally think that insurance plans should cover the costs of prescriptions that are needed daily.
    But this comes down to a discussion of the whole system–should insurance be for catastrophic coverage, or should it be a medical care plan as well? If its somewhere in-between(as it is now for most US residents), who decides what is covered?
    On a side note, I found out our cancer center charges Medicaid patients a $3 co-pay. This is just punitive–it costs the hospital that much just to process the payment. Since Medicaid patients make less than about $650 per month, those co-pays do add up.

  11. #11 mho
    December 27, 2013

    edit: if they offer mail order

  12. #12 Canonical
    December 27, 2013

    I hate that insurance companies are allowed to place drugs into “tiers”–tiers that allow them to stick their insured with any co-pay they want. I was prescribed fenofibrate as was my husband. My doctor put me on a lower dose than husband’s. Since my dosage was “third tier” it would’ve cost $360-odd dollars for a 30 day supply. My husband’s dosage was “second tier” and the insurance covered more of the cost. His cost for 30 days? About $45. More medication at a lower cost because of the insurance company-created tier system. I asked my doctor to switch me back to simvastatin.

    (Before anyone yells, “If you’d just watch your diet…!”, we’re eating under 900mg of cholesterol a week and both of our cholesterol levels continue to go up. We both have a genetic propensity to accumulate bad cholesterol.)

  13. #13 Johanna
    December 27, 2013

    @canonical

    Worry not, folks around here only condemn lifestyle choices if those choices lead to coffee enemas and such. Otherwise, we’re a pretty laid-back bunch. ;)

  14. #14 Mrs Woo
    The wilds of Missouri
    December 27, 2013

    Some of us don’t pay for Costco memberships, especially when it is a 45-minute drive one-way to get there. I immediately reflected on my current injury, a scaphoid fracture. A few weeks earlier, my son complained of wrist pain as well, and both I and the doctor agreed that the manner of injury plus location of the pain and what made it worse made fracture unlikely, and decided to wait two weeks to see if it cleared up with an ace wrap and reduced weight training (J is so proud to be able to bench press 270! – he is only 15).

    Since I’m on a limited income, if for some reason I was told that a sore wrist after a fall roller skating (yes, someone my age shouldn’t have done that, but nine-year-olds, birthday parties… sometimes you make decisions based on emotion) didn’t indicate an x-ray, I might have chosen to skip it. I broke the scaphoid in the lower part of the bone, a place that has a terrible outcome healing, and am a musician. Developing complications from this would have been very upsetting. As it is, we have follow-up x-rays scheduled on Monday to see if it is healing together or if it’s time for an ortho referral.

    I am probably borrowing trouble, but I have had the misfortune of watching a good friend in an aggressively cost-managed HMO spend a year complaining about headaches that were not normal for him before he finally could be approved for a specialist referral. By that time the brain tumor was inoperable. We don’t know that it was always that way, I realize that, but we often have our “what-if” moments where we wonder if it had been dealt with when he first complained if his life might have been extended or saved.

    If it goes down to “no x-rays without cost sharing” (I realize the example shared was a case that was really unlikely to require x-rays or other imaging studies), especially with many primary care providers having digital x-ray equipment in their offices, I worry that there will be a subset of patients who might become reluctant to seek treatment at all for fear of the costs they might incur.

    I admit it – I don’t like change (I realize that this isn’t a set-in-stone plan; I also realize it sounds like something that might be incredibly appealing to insurance companies). I also hate insurance companies (so does my primary care physician, poor guy).

  15. #15 mho
    December 28, 2013

    I think you can fill prescriptions at Costco without being a member.

  16. #16 Mrs Woo
    a zoo...
    December 28, 2013

    Even if that might be so, I believe you have to be a member to get OTC and other off the shelf products.

  17. #17 Shay
    December 28, 2013

    I took my current job in public health in September 2009, and immediately began to learn more about viruses, particularly flu viruses, than I had ever known before.

    So when I got sick about six months later, went to the doc, was diagnosed with a virus and she offered me antibiotics, I virtuously turned them down. Her response? “Well, they don’t hurt.”

    She wasn’t a bad doctor, I think maybe she just was so used to people demanding antibiotics that my refusal threw her.

    Mrs Woo, there was a time in my life, fortunately briefly, when I had no health insurance, my then-doctor knew it, and he tried to prescribe OTC whenever he could because he knew it was cheaper for me. Oh wait…I forgot. Doctors are evil peepul who only care about making money.

    Johanna, speaking as a confirmed coffee-fiend (in the US military, coffee is known as lifer-juice, referring to the senior staff noncommissioned officers who must have coffee regardless of time, tide, or tactical situation. Bill Mauldin has a cartoon about it), I consider coffee enemas to be a sin against man AND nature.

    Why on earth would anyone waste perfectly good coffee??!!

  18. #18 Canonical
    December 28, 2013

    @13 Johanna
    Thanks! I’m still a little sensitive about it having, finally, to keep a journal of precise weights of everything I ate since my doctor was sure I was eating sticks of butter like lollipops. The week prior to a cholesterol check (where I’d eaten 30mg of cholesterol (in a week!), and the blood test came back higher than before, finally convinced him that “watching my diet” wasn’t working.

    @ #15 mho; no, you don’t have to be a member to use a Costco pharmacy. Depending on the store, they may require you to wait until an employee can escort you over to the pharmacy, but all you have to tell them at the door is that you are going to the pharmacy.

  19. #19 Mrs Woo
    December 28, 2013

    I was pointing out to MHO that the discussion about saving money on OTC products at Costco isn’t helped by the fact non-members can use the pharmacy. I also was uninsured for a time and my marvelous primary care doctor also managed my costs to the best of his ability. Please don’t be misled by my name. It is because I am married to someone who is a true believer in alt-med who has wasted 100s a month trying to cure the incurable that I chose it as my ‘nym…

  20. #20 Mrs Woo
    December 28, 2013

    Also, I don’t blame doctors for our friend’s death. I blame his HMO and its aggressive cost-managing policies. If I were the one enamored with alt-med, I wouldn’t be frustrated that he was denied life-extending science-based treatment.

    I will say it again. I hate insurance companies. So do most doctors I know, by the way. ;-)

  21. #21 Bob G
    Los Angeles
    December 28, 2013

    Back when Ross Perot was running for president, he made a remark that struck me as not unreasonable. He said that if we couldn’t figure out our own health care payment system, then we should at least look at the other systems and copy the best one. We have several possible alternatives, including France, Germany, Britain, and at least a couple of east Asian countries. They all do things at less overall cost, and they generally compete in areas like longevity, infant mortality, and more than compete in patient satisfaction.

    One thing that most of the alternatives have in common is some overall control of costs at every level. That includes pharmaceuticals, physician salaries, salaries to other healthcare workers, and yes, some equivalent to the dreaded “death panels.” For example, the NHS has been famous for refusing to spend hundreds of thousands of dollars (or pound equivalents) on ineffective palliative treatments for end stage cancer. Nothing like Sarah Palin’s silliness, but some concern over wasting huge amounts of money on end of life care.

    I appreciate doctors being sensitive to costs and doing their best to mitigate them as best as possible, but it is the overall system that is lacking. The following remark is more appropriate to an entire full length essay in another forum, but I would point out in passing that the US government could fund 100,000 medical students at $100,000 per year each, for a total cost of ten billion dollars per year. That is what the politicians call “budget dust,” and it would end all the concerns among young doctors regarding making lots of money to pay off their debts. I suppose that another ten billion or so would cover a lot of residencies (at least in terms of salaries). Since the number of first year medical students is expected to grow to about 21,000 over the next five years, there aren’t even enough students to use that full ten billion dollars right now. Most other industrialized western countries do, in fact, cover the costs of medical education out of taxes, and it seems to help.

  22. #22 Mrs Woo
    December 28, 2013

    I agree that covering education costs for medical professionals (and other very necessary degrees) is a great idea. There are intelligent people out there who forego pursuing education based on the cost and the large student loan debt they might incur reaching there goals.

    Further, it might motivate some students to choose some courses of study based on being able to afford them more ably than, say, becoming a scholar in 16th century French literature.

  23. #23 palindrom
    December 28, 2013

    I remember years ago proposing that the government fund ALL of the costs for medical students; I also proposed that each newly-minted MD be presented with a brand-new Porsche, the catch being that later in life their reimbursement rates would be kept in check. It’d save a fortune in the long run.

  24. […] Is “value-based’ health insurance really “value-based” or is it just an excuse to pay more? Respectful Insolence […]

  25. #25 Spring Texan
    January 1, 2014

    Bob G., Mrs. Woo, and palindrom, love your idea of paying medical education costs. It would also make doctors less mentally stressed and able to focus on medicine.

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