02 May 2007

Beyond (De)Capitation

Note: Shout-outs to Janine Mendes-Franco, who selected another of My recent posts for Global Voices Online and to Raúl José, of De todo como en botica, for including Me in his analysis of Stupid Rosselló's pathetic mewl for attention.

From a dear friend, much more evidence beyond capitation that the health care system is a mangled wreck. Statehooders, try to understand that the following happened in the States, okay?

The whole area of medical care is COMPLETELY MESSED UP (and capitation is just one symptom of that).

My main complaint--medical care is basically the ONLY place where the price tag associated with something is completely irrelevant to the end user. People want to walk into a pharmacy and pay their $10 co-pay, regardless of the cost of the drug. Consumers have NO incentive to make rational decisions because they are shielded from the actual cost of care. (Why SHOULD I take the generic or an older drug if my copay is the same for the spiffiest name-brand drug? And why should I take over-the-counter Claritin and pay the full cost when I can take Zyrtec which is still covered under my drug plan?)

You also don't see the price tag until it's too late. Look at Don's broken toe from last year. His $1000 toe. He went to an emergency room at a facility on our list of "Approved Providers." We got their bill - $500 - even though he never got past the waiting room and a triage "curtain." Then we got the doctor's bill - $455. The doctor spent less then 3 minutes with Don. Looked at his toe, gave it a mighty yank, and told an assistant to "buddy-tape" it. For that, we were billed for two separate procedures (one labeled "SURGERY"). That's a heck of an hourly billing rate. And the story gets better... The doctors in the emergency room aren't a part of ANY insurer's plan. They can charge whatever they please and you just have to pay it. No negotiated fees. No discounts. Do not pass go, and pay way more than $200. AND--this is the kicker--although they don't recognize our insurance, because we HAVE insurance, they wouldn't discount the bill (claimed they "COULDN'T"). So we were stuck paying their highway robbery rate of $455. The only reasonable bill was from the radiologist - $11.55 to read the x-ray.

We TRIED to shop--went to what we THOUGHT was a facility covered by our plan. But there's no transparency in the pricing or anything else in the process. That's one of my problems with it.

I have a pharmacist friend in Louisiana who works with a lot of Medicaid patients. Because THEY aren't paying ANYTHING for their prescriptions, it is amazing how picky they can be. They get the name-brand drugs (no generic drugs for them - those are reserved for the paying customers with insurance). She's had parents return a drug because, "My child didn't like the taste of it." They wanted a different drug, AND THE DOCTOR GAVE IT TO THEM. (My child would have been told, "Swallow it. I know it tastes bad, but GET OVER IT.")

Society wants the easy fix ("diet and exercise" would sometimes work as well as a drug, but we want to be able to "supersize our fries," then take a pill for our cholesterol). What happened to personal responsibility? If you watch the drug ads, it doesn't need to exist. Pharma has a cure for whatever ill you may have or think you have. Drug ads make me crazy.

There are too many special-interest groups with VERY vested interests in maintaining the status quo. There are many INDIVIDUALS who like the status quo, too (mainly those with rich employer-provided health plans - just even WHISPER about changing a health plan at a unionized facility and watch the union squawk).

If there isn't a link between the COST and the SERVICE, then individuals will naturally want the most expensive (not most cost-effective) option. People have no incentive to self-regulate their demand for services, or to seek the most cost-efficient options. To me, that indicates a broken system. There will be no easy fixes, and fixes will not be popular.

We have a $10k deductible. I have plenty of reason to try to control what I am paying, but I'm not given the tools to do it. (Just look at our toe experience...)

Imagine: The richest, most successful country in history has a health-care system built on any number of factors... except actual health-care. And rather than seek a better solution, We play "Monkey see, monkey do".

However, in Our defense, so long as We are beholden to the Big Monkeys from the north--Medicare, insurance companies, pharmaceutical companies, etc.--and their incessant lobbying to keep a broken system broken, We'll just have to play along. It's not like We've ever had a real doctor in charge to try to make a difference, right?

The Jenius Has Spoken.

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