Healthcare reform

[kapkomet]

kap, you seem to be acknowledging that the current system is broken and something needs to be done, and I'm guessing you're just opposing the idea of the government running it or extending healthcare to uninsured. What are you proposing be done?

It's like this:

 

You take your car in - you get a quote for services. You know what will be fixed and at what cost.

 

You go to the doctor, and you have no clue what it costs because you have insurance taking care of it, on a predeterminded basis... symptoms are XYZ, we have to run ABCDEFGH tests. Are all of these tests needed? NO!

 

The biggest problem is doctors are held to a standard that should not be. They order so much crap that is unneeded because they have to cover their ass for insurance and liability reasons. Talk about wasteful spending. That's where a lot of it goes right there. There has to be a way to reform this part so that a doctor doesn't order crap just to CTA. This would help immensely. This is where tort reform comes in. There's lawyers that just sit and wait for a dx to be made that is in error so they can start the lawsuits. There MUST be some reform in this area. These two concepts go hand in hand.

 

The other part, as I alluded to, people have no concept of health care costs unless they're self pay. Then it becomes painfully obvious. There's a huge disconnect here and it is one that needs to at least be bridged.

 

Then there's the "usual and customary" clauses (gross revenues). IMO, this whole thing is collusion on the parts of the insurance companies. This whole area needs to be reformed. That's driving up costs so sky high it's ridiculous.

 

Pharma companies should have caps on how much they can raise prices in a year. I do NOT favor restricting the amounts of drugs sold in a year, like they do in Europe. But they should have limitations on how much they sell. The place I worked - corporate needs more money - we'll just raise prices! Woot! There's no justification needed beyond that, and that's a sham of a system. I'm a free market guy - and notice what I'm saying. For me to say this, it's a problem that needs to be addressed.

 

So, I've talked about doctors, insurance, pharma, lawyers. This should be the start of a good conversation, if people actually participate this time.

 

(you can move this if you deem it worthy enough for its own thread - the whole health care thing - this is obviously only the beginning of this debate)

[lostfan]

Nice, kap, you weren't as far away from my (admittedly not very firm) stance as I thought.

[Balta1701]

The biggest problem is doctors are held to a standard that should not be. They order so much crap that is unneeded because they have to cover their ass for insurance and liability reasons. Talk about wasteful spending. That's where a lot of it goes right there. There has to be a way to reform this part so that a doctor doesn't order crap just to CTA. This would help immensely. This is where tort reform comes in. There's lawyers that just sit and wait for a dx to be made that is in error so they can start the lawsuits. There MUST be some reform in this area. These two concepts go hand in hand.

Then why haven't states that have put caps on malpractice settlements seen huge drops in healthcare spending?

 

I will certainly agree that doctors order a lot of stuff that doesn't need to be done, but I'm going to go with a different reason why; profit. It's a symptom of a broken market. There is no downside to a doctor ordering too much treatment; there is only upside, in that it drags more money in to the system. It's like that article about the highest per capita health care costs in the country spot in Texas i cited a week or two ago...doctors down the road order dramatically less stuff and spend less money. It's not because the high expenditure area is more scared of malpractice suits; the costs are capped in both places, it's that the extra providers there are making a killing offering more and more expensive and unnecessary treatments.

 

This is why something called "Comparative effectiveness research" is so important. It's something the insurance and medical industries are strongly against, because the more they can keep doctors in the dark about how effective the treatments they order actually are, the more they can rake people over the coals. The problem is, right now, the anti-reform folks have decided that denying someone a prescription for a product that is more expensive and less effective than something on the market as generic (i.e. Clarinex vs. Claritin) is a form of rationing, and that's an evil word that we'd never consider doing (as long as "we" aren't an insurance company, for them it's ok), so we always have to pay for the highest cost treatment...because for the people with the best lobbyists, the highest cost treatment is the highest profit treatment.

[kapkomet]

Then why haven't states that have put caps on malpractice settlements seen huge drops in healthcare spending?

 

I will certainly agree that doctors order a lot of stuff that doesn't need to be done, but I'm going to go with a different reason why; profit. It's a symptom of a broken market. There is no downside to a doctor ordering too much treatment; there is only upside, in that it drags more money in to the system. It's like that article about the highest per capita health care costs in the country spot in Texas i cited a week or two ago...doctors down the road order dramatically less stuff and spend less money. It's not because the high expenditure area is more scared of malpractice suits; the costs are capped in both places, it's that the extra providers there are making a killing offering more and more expensive and unnecessary treatments.

 

This is why something called "Comparative effectiveness research" is so important. It's something the insurance and medical industries are strongly against, because the more they can keep doctors in the dark about how effective the treatments they order actually are, the more they can rake people over the coals. The problem is, right now, the anti-reform folks have decided that denying someone a prescription for a product that is more expensive and less effective than something on the market as generic (i.e. Clarinex vs. Claritin) is a form of rationing, and that's an evil word that we'd never consider doing (as long as "we" aren't an insurance company, for them it's ok), so we always have to pay for the highest cost treatment...because for the people with the best lobbyists, the highest cost treatment is the highest profit treatment.

One thing I will say is "rationing" is ok, as long as it's not "rationing" for providing services.

 

The doctors thing: one of the biggest challenges is there are at least two (if not more) standards the docs are held to. Their license may require different expectations (read: treatment outcomes) depending on which medical board it goes through. This does cause a difference in how they treat a dx. I think that's wrong, and a big problem. (I.e. an internist goes through a different treatment then a general practitioner). Then you tie that in to malpractice, insurance, etc. You can't forget that when you're talking about the malpractice stuff. That cap is really just a bs thing - because it only comes into play at rare cases.

 

Another pharma trick is the reformulation of things just to escape patent renewals. I think that's horses***. Let's move the carbonate molecule from one branch to another, call it something different (when in fact it's the same drug) and remarket it. Yea, that's fair.

 

 

 

 

[ThunderBolt]

Moving past the pros and cons debate over universal healthcare. Can the argument be made that it is really something we should be prioritizing on now?

[lostfan]

Moving past the pros and cons debate over universal healthcare. Can the argument be made that it is really something we should be prioritizing on now?

Are you saying it should or shouldn't be? I say it should, because if some kind of reform doesn't happen, it'll be pushed off another decade or so at least. And if for no other reason, than because of the fact that the costs are spinning out of control and it's killing our long-term budget.

[bigruss]

One thing I will say is "rationing" is ok, as long as it's not "rationing" for providing services.

 

The doctors thing: one of the biggest challenges is there are at least two (if not more) standards the docs are held to. Their license may require different expectations (read: treatment outcomes) depending on which medical board it goes through. This does cause a difference in how they treat a dx. I think that's wrong, and a big problem. (I.e. an internist goes through a different treatment then a general practitioner). Then you tie that in to malpractice, insurance, etc. You can't forget that when you're talking about the malpractice stuff. That cap is really just a bs thing - because it only comes into play at rare cases.

 

Another pharma trick is the reformulation of things just to escape patent renewals. I think that's horses***. Let's move the carbonate molecule from one branch to another, call it something different (when in fact it's the same drug) and remarket it. Yea, that's fair.

Oh yea, its really fair that a product you invest millions of dollars into is only under your protection for a few years before generic companies come in and steal your patent and make a ridiculous amount of money with very little R&D costs. Thats fair alright.

[kapkomet]

Oh yea, its really fair that a product you invest millions of dollars into is only under your protection for a few years before generic companies come in and steal your patent and make a ridiculous amount of money with very little R&D costs. Thats fair alright.

 

I worked at a pharma company. I know how this game is played. Generic companies "steal" your business? OK. If you have a good product, you'll make billions off of it before the patent expires anyway. You have a lot of years of patent protection. And if the pharma company can't get it to market and make money off of it, it's their own fault.

[bigruss]

 

I worked at a pharma company. I know how this game is played. Generic companies "steal" your business? OK. If you have a good product, you'll make billions off of it before the patent expires anyway. You have a lot of years of patent protection. And if the pharma company can't get it to market and make money off of it, it's their own fault.

I work at one currently. I am only an intern, and Im not in the R&D side, Im in the IT part, but from what Ive heard you only get a few years of actual selling time because of FDA requirements and testing.

 

Pharmas are constantly trying to improve their rate and speed of getting out their products, but the chances are small for many of their products and the obstacles a numerous, with many of them unknown until the FDA tells you so. You can prepare your documents as best you can for the FDA but if they feel any slight discomfort in allowing the drug on the market, they'll ask for more testing and you can easily see a year or two knocked off your time frame of the patent.

 

Luckily the one I am working at specializes in transplant medicine and it is much harder to make a generic copy.

[kapkomet]

I work at one currently. I am only an intern, and Im not in the R&D side, Im in the IT part, but from what Ive heard you only get a few years of actual selling time because of FDA requirements and testing.

 

Pharmas are constantly trying to improve their rate and speed of getting out their products, but the chances are small for many of their products and the obstacles a numerous, with many of them unknown until the FDA tells you so. You can prepare your documents as best you can for the FDA but if they feel any slight discomfort in allowing the drug on the market, they'll ask for more testing and you can easily see a year or two knocked off your time frame of the patent.

 

Luckily the one I am working at specializes in transplant medicine and it is much harder to make a generic copy.

Most of the time, you know what the FDA is going to request. Of course speed to market is the whole thing and yes, you only have a short window. With that said, moving an end of a chain on a molecule and then selling the drug as a new formulation to keep the insane profits down is crazy. And you know exactly what the FDA is going to do with those reformulations because you've already been down the path with the original molecule.

 

 

[Soxbadger]

The biggest problem is doctors are held to a standard that should not be. They order so much crap that is unneeded because they have to cover their ass for insurance and liability reasons. Talk about wasteful spending. That's where a lot of it goes right there. There has to be a way to reform this part so that a doctor doesn't order crap just to CTA. This would help immensely. This is where tort reform comes in. There's lawyers that just sit and wait for a dx to be made that is in error so they can start the lawsuits. There MUST be some reform in this area. These two concepts go hand in hand.

 

In another thread I posted about Dr. malpractice being one of the greatest myths.

In order for a Dr to even be sued for malpractice another Dr. must certify that there was negligence.

 

That is why so many malpractice cases settle, because before the case can even be filed an expert needs to independently state that there was malpractice.

 

If a Dr is negligent, why should the victim not be able to fully recover?

 

If we cap medical malpractice torts, we should cap every tort because no victims should ever be able to fully recover.

 

/shrugs

 

I made a much better post on this topic before, so im not going to rehash it all, its some where in this forum.

 

 

[kapkomet]

In another thread I posted about Dr. malpractice being one of the greatest myths.

In order for a Dr to even be sued for malpractice another Dr. must certify that there was negligence.

 

That is why so many malpractice cases settle, because before the case can even be filed an expert needs to independently state that there was malpractice.

 

If a Dr is negligent, why should the victim not be able to fully recover?

 

If we cap medical malpractice torts, we should cap every tort because no victims should ever be able to fully recover.

 

/shrugs

 

I made a much better post on this topic before, so im not going to rehash it all, its some where in this forum.

So what? This is part of the equation.

 

Once the case gets to a lawsuit, which is whre your point lies, I agree.

 

More thoughts that was triggered by this post and others before it.

 

A ton of doctors order crap just to cover their butts. Just on the CHANCE that there's a lawsuit going to happen. And as I said earlier in this thread, there's too many different standards depending on the licensing board - that's ultimately where a lot of the power lies. It's a problem... because it's gotten too far out of hand, and now there's a lot of stuff just being done for the sake of being done. Remember, (here comes Balta's counter), the original doctor often refers to another place (diagnostics, lab, scans, xray, whatever) - and they don't get paid on these ICD9 (dx) codes or CPT codes (services provided for billing).

 

When I worked in medical (not pharma), I personally instructed clinicians how to code to get more money. They could only spend 30 seconds asking a certain set of questions and put a CPT code down which would get reimbursed at a higher rate. That's part of the problem, and a huge overhaul of dx and reimbursement codes needs to be done so it's more uniform and consistent.

[Balta1701]

In another thread I posted about Dr. malpractice being one of the greatest myths.

In order for a Dr to even be sued for malpractice another Dr. must certify that there was negligence.

 

That is why so many malpractice cases settle, because before the case can even be filed an expert needs to independently state that there was malpractice.

 

If a Dr is negligent, why should the victim not be able to fully recover?

 

If we cap medical malpractice torts, we should cap every tort because no victims should ever be able to fully recover.

 

/shrugs

 

I made a much better post on this topic before, so im not going to rehash it all, its some where in this forum.

In terms of malpractice there's actually a lot that can be done as well. There are some simple steps, like better standardization of procedures at hospitals for cleanliness, that can cut those sorts of issues in half. And...I'm not going to be able to find the data for the whole country, but a significant %age of malpractice claims are actually made against a fairly small number of repeat offenders, who medical boards typically will not discipline. Since patients have no access to that type of data, there's really no punishment for being bad at your job.

[bigruss]

Most of the time, you know what the FDA is going to request. Of course speed to market is the whole thing and yes, you only have a short window. With that said, moving an end of a chain on a molecule and then selling the drug as a new formulation to keep the insane profits down is crazy. And you know exactly what the FDA is going to do with those reformulations because you've already been down the path with the original molecule.

Doesnt sound crazy to me, sounds like a business trying to keep profits high and keep the return coming on their investment.

[kapkomet]

Doesnt sound crazy to me, sounds like a business trying to keep profits high and keep the return coming on their investment.

Like I said, I'm a free market guy - let things go as they go... but pharma is one industry that I have some integrity issues with... because at whose cost is a reformulation going to come from.

 

Drug A - $300 for 30 pills

Drug A generic - $45 for 30 pills

Drug AB (redformulated) - $330 for 30 pills (with all sorts of new marketing campaigns to allow for the "degradation" of drug A and drug A generic (which provides the same result as drug AB)).

 

The reality is most times, marketing spend for "Drug A" and "Drug AB" will be the same in the budgets once the switch is made, so they're making 10% more off of the reformulation for no reason other then a name change - all because of a patent expiration.

 

The other thing I'll say - pharmas COULD do it different with generic companies - they could have agreements (some do, most don't) in place to maintain control over the generics - but they don't because the profits aren't enough.

 

[kapkomet]

In terms of malpractice there's actually a lot that can be done as well. There are some simple steps, like better standardization of procedures at hospitals for cleanliness, that can cut those sorts of issues in half. And...I'm not going to be able to find the data for the whole country, but a significant %age of malpractice claims are actually made against a fairly small number of repeat offenders, who medical boards typically will not discipline. Since patients have no access to that type of data, there's really no punishment for being bad at your job.

And for me, that's where the "reform" needs to take place. Not turn it over to the government, or "universal coverage".

 

As I said last night as well, I do want to see more on the "co-op" idea that's being floated around. I wonder if that's window dressing or if it is a real compromise of sorts.

 

[lostfan]

Doesnt sound crazy to me, sounds like a business trying to keep profits high and keep the return coming on their investment.

That's really part of the problem IMO. The fact that money is the bottom line. We're not talking about a flavor of soft drink, or a Blu-Ray player, or a website, we're talking about people's health. And furthermore, the consumer base doesn't have any kind of control over it because they can't see it, so I don't even really think the free market/laissez-faire argument is that valid anyway. They shouldn't be allowed to just extract profits from us because they want to, and because they can.

[bigruss]

Like I said, I'm a free market guy - let things go as they go... but pharma is one industry that I have some integrity issues with... because at whose cost is a reformulation going to come from.

 

Drug A - $300 for 30 pills

Drug A generic - $45 for 30 pills

Drug AB (redformulated) - $330 for 30 pills (with all sorts of new marketing campaigns to allow for the "degradation" of drug A and drug A generic (which provides the same result as drug AB)).

 

The reality is most times, marketing spend for "Drug A" and "Drug AB" will be the same in the budgets once the switch is made, so they're making 10% more off of the reformulation for no reason other then a name change - all because of a patent expiration.

 

The other thing I'll say - pharmas COULD do it different with generic companies - they could have agreements (some do, most don't) in place to maintain control over the generics - but they don't because the profits aren't enough.

So you're saying the profit isnt high enough for pharmas to make deals with generic companies, okay fine. Then why should they change from what they are doing? If they feel the best business is to keep reformulating the drug, why not?

 

Do I think they should raise the prices? Personally, no. But when a company strives to make the most profits possible this is what happens. Unless you want government intervention or reform of the laws in place, this is what is going to happen as long as generics are threatening to take away profit.

[NorthSideSox72]

That's really part of the problem IMO. The fact that money is the bottom line. We're not talking about a flavor of soft drink, or a Blu-Ray player, or a website, we're talking about people's health. And furthermore, the consumer base doesn't have any kind of control over it because they can't see it, so I don't even really think the free market/laissez-faire argument is that valid anyway. They shouldn't be allowed to just extract profits from us because they want to, and because they can.

I've brought this up before as well. Health Care is one of the few areas where the motivations of value and profit between business and consumers just does not work well. You can't leave it purely to market forces.

 

OTOH, you can't just institutionalize everything either.

 

IMO, a good part of the solution here should be the encouragement (at least) of not-for-profit but private entities running health care facilities and insurance.

 

[bigruss]

That's really part of the problem IMO. The fact that money is the bottom line. We're not talking about a flavor of soft drink, or a Blu-Ray player, or a website, we're talking about people's health. And furthermore, the consumer base doesn't have any kind of control over it because they can't see it, so I don't even really think the free market/laissez-faire argument is that valid anyway. They shouldn't be allowed to just extract profits from us because they want to, and because they can.

Theyre still a business that is trying to make as much profit as possible, you take that away you threaten to take away their resources to reinvest into R&D, and then everybody hurts because less advancements in medicine are made.

[lostfan]

Theyre still a business that is trying to make as much profit as possible, you take that away you threaten to take away their resources to reinvest into R&D, and then everybody hurts because less advancements in medicine are made.

I'm not really buying it... unless the entire industry was taken over and run as a government agency and not for profit (which isn't going to happen), they will still get their profits. They just won't be able to gouge and contribute to exploding costs like they do now. If I had my way, anyway.

Edited June 11, 2009 by lostfan

[bigruss]

I'm not really buying it... unless the entire industry was taken over and run as a government agency and not for profit (which isn't going to happen), they will still get their profits. They just won't be able to gouge and contribute to exploding costs like they do now. If I had my way, anyway.

Well, their big profits come in those short periods of time that they can sell their drugs under patent, so they basically are forced to sell them at such a high price. They need to get as much money as possible in that time so they can accumulate a nice amount for new drugs, and obviously they are making nice money at the same time but thats what a business does.

[lostfan]

Well, their big profits come in those short periods of time that they can sell their drugs under patent, so they basically are forced to sell them at such a high price. They need to get as much money as possible in that time so they can accumulate a nice amount for new drugs, and obviously they are making nice money at the same time but thats what a business does.

I'm not saying that the motive for profit in and of itself is a bad thing, because when you run a business that's what you do. I'm saying that in this particular case I'm all for tighter regulation and more government involvement than I would normally be because it's a different situation.

[Soxbadger]

A ton of doctors order crap just to cover their butts. Just on the CHANCE that there's a lawsuit going to happen. And as I said earlier in this thread, there's too many different standards depending on the licensing board - that's ultimately where a lot of the power lies. It's a problem... because it's gotten too far out of hand, and now there's a lot of stuff just being done for the sake of being done. Remember, (here comes Balta's counter), the original doctor often refers to another place (diagnostics, lab, scans, xray, whatever) - and they don't get paid on these ICD9 (dx) codes or CPT codes (services provided for billing).

 

The problem with this excuse is it doesnt really hold water (imo). To win on a negligence/medical malpractice case you must prove that the Dr's actions fell below the "established standard of care." So ordering useless tests isnt really going to help, because if they were tests that arent part of the "established standard" not running them wouldnt make you negligent.

 

Negligence is when the Dr knew that they were supposed to do X, and instead did Y or just did nothing, or maybe even did X, but much slower than they should have.

 

From my experience the reason why Dr's run so many tests is due to how they get paid by insurance. They can claim ridiculous amounts for the tests which the insurance company generally pays and they make a lot of money on those unnecessary tests.

 

There are a lot of ways that malpractice against Dr's can be fixed, the problem is the Dr lobby is really good because Dr's are portrayed as victims.

[Balta1701]

Well, their big profits come in those short periods of time that they can sell their drugs under patent, so they basically are forced to sell them at such a high price. They need to get as much money as possible in that time so they can accumulate a nice amount for new drugs, and obviously they are making nice money at the same time but thats what a business does.

The biggest problem with that setup not being talked about here is that it also puts the profit motive in the wrong direction. The most profitable pill for a company to develop is not going to be the one that makes the greatest number of people healthy or cures a disease the easiest; it's the one that people have to take every day for the entire time that it is under control of their patent. So, instead of drugs that could be targeted towards curing things, we get drugs that manage symptoms, or drugs that are aimed at things that really aren't life threatening. You wind up with erectile dysfunction drugs and antidepressants being the most profitable type of drugs, while necessary things like improving our vaccine manufacturing languishes because you only need that one time per year.