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debt collection at the hospital?
Posted: 04 May 2012 11:04 PM   [ Ignore ]   [ # 31 ]
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I’m a Canadian. A few years ago, my wife had what turned out to be a severe panic attack that looked like a heart problem. I called 911, the ambulance appeared, medics tended my wife and called in the heart medics in another ambulance. My wife was hospitalized for observation and taken to a larger hospital, about 50 miles away the next day, for detailed testing of the heart and then returned to her local hospital for release. I drove in for her tests and drove home to pick her up from our local hospital. As a senior citizen the only cost to me was the m$2 parking lot fee in the city but when younger I would have received the same service for a relatively low cost insurance charge ($80 to $150) per month.

You have my sympathies but as a nation your medical cost problem can be fixed as other nations have done.

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Posted: 23 May 2012 12:07 PM   [ Ignore ]   [ # 32 ]
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Canada’s health care isnt sustainable though, is it unrealistic to expect some sort of co-pay. How many idiots go to emergancy room to sober up or over petty things.

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Posted: 26 May 2012 06:34 PM   [ Ignore ]   [ # 33 ]
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You’re right. Any sustainable healthcare system must require some payment from the patient to reduce misuse and overuse of services. It shouldn’t be onerous but it should be enough to make the person think about whether they really need the service. Medical care should never be completely free.

I’ve seen patients call an ambulance rather than a cab to go to the emergency room because their insurance covered the ambulance and they didn’t want to pay cab fare. I’ve had lots of patients ask for tests they didn’t need with the rationale that “this is what i pay premiums for and it wont cost me anything”. Copays should somehow be linked to income though. $20 might be prohibitive for someone who is poor but wealthier people won’t even flinch at that. The co-pay has to be large enough to cause a small amount of pain no matter who the person is.

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Posted: 27 May 2012 07:07 AM   [ Ignore ]   [ # 34 ]
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macgyver - 26 May 2012 06:34 PM

You’re right. Any sustainable healthcare system must require some payment from the patient to reduce misuse and overuse of services. It shouldn’t be onerous but it should be enough to make the person think about whether they really need the service. Medical care should never be completely free.

I’ve seen patients call an ambulance rather than a cab to go to the emergency room because their insurance covered the ambulance and they didn’t want to pay cab fare. I’ve had lots of patients ask for tests they didn’t need with the rationale that “this is what i pay premiums for and it wont cost me anything”. Copays should somehow be linked to income though. $20 might be prohibitive for someone who is poor but wealthier people won’t even flinch at that. The co-pay has to be large enough to cause a small amount of pain no matter who the person is.

why should I pay 50 dollars for a cup of coffee when some homeless fellow pays a nickel.

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Posted: 27 May 2012 11:00 AM   [ Ignore ]   [ # 35 ]
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why should I pay 50 dollars for a cup of coffee when some homeless fellow pays a nickel.

You shouldn’t.  The discussion isn’t about cups of coffee though.
Why would anyone pay $50 for a cup of coffee?  That’s ridiculous!
There shouldn’t be co-pay for insurance period.  It’s sensible to think about reducing the amount of frivolous abuse in the health care industry. However that’s on the health care industry-not the payer.
The health care industry has created the climate of accepting all comers for money.  As long as someone’s paying, an emergency room or doctor’s office will treat someone for any ailment they complain of.
And by and large someone’s paying.
The government should impress upon healthcare providers to use more discretion in the frivolous treatment of hypochondriacs and minor injuries and or pain or sickness-for those people opting for the Universal Government Insurance.
The people who pay for their care out of their own pockets or with private insurance can go to the doctor every other day with frivolous issues.  There will be doctors or centers willing to treat them.

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Posted: 27 May 2012 11:10 AM   [ Ignore ]   [ # 36 ]
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VYAZMA - 27 May 2012 11:00 AM

why should I pay 50 dollars for a cup of coffee when some homeless fellow pays a nickel.

You shouldn’t.  The discussion isn’t about cups of coffee though.
Why would anyone pay $50 for a cup of coffee?  That’s ridiculous!
There shouldn’t be co-pay for insurance period.  It’s sensible to think about reducing the amount of frivolous abuse in the health care industry. However that’s on the health care industry-not the payer.
The health care industry has created the climate of accepting all comers for money.  As long as someone’s paying, an emergency room or doctor’s office will treat someone for any ailment they complain of.
And by and large someone’s paying.
The government should impress upon healthcare providers to use more discretion in the frivolous treatment of hypochondriacs and minor injuries and or pain or sickness-for those people opting for the Universal Government Insurance.
The people who pay for their care out of their own pockets or with private insurance can go to the doctor every other day with frivolous issues.  There will be doctors or centers willing to treat them.

I dont know how things are in the glorious Christian nation known as the US of A.  (america was not founded a christian nation, but it is safe to say they hijacked it) but in Canada the emergancy rooms are government, and free, and they cant turn people away. So people go in for all sorts of ridiculous stuff. My son has a cold, etc etc. It has gotten to the point that waiting times for a broken bone can be 18 hours. The costs are ballooning, so yes, we need a copay. Socialism is great on paper my friend, but capitalism is the only system that punishes idiots without infringing on their rights, so we do need it.

And dont even get me started on the National Health Service in mother England, thank goodness there is a separate private system there.

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Posted: 27 May 2012 11:36 AM   [ Ignore ]   [ # 37 ]
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zmullin-I dont know how things are in the glorious Christian nation known as the US of A.  (america was not founded a christian nation, but it is safe to say they hijacked it) but in Canada the emergancy rooms are government, and free, and they cant turn people away. So people go in for all sorts of ridiculous stuff. My son has a cold, etc etc. It has gotten to the point that waiting times for a broken bone can be 18 hours. The costs are ballooning, so yes, we need a copay. Socialism is great on paper my friend, but capitalism is the only system that punishes idiots without infringing on their rights, so we do need it.

And dont even get me started on the National Health Service in mother England, thank goodness there is a separate private system there.

Fine, then co-pays must be $20.  This covers initial visit for specific ailment.  Follow up treatments for same ailment are free.  New ailments bring new co-pay of $20.
The doctor determines if follow up treatments are necessary. If the doctor determines it’s frivolous then it’s a done deal, no free follow up visits.  Otherwise each new frivolous visit costs $20.
The government will set standards for preventing overlapping diagnoses or what can and cannot be considered frivolous. Or what can be called “follow-up” treatments.
Again those able to afford other insurance, or pay out of pocket are welcome to indulge their hypochondriatic fantasies all week long.

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Posted: 27 May 2012 01:07 PM   [ Ignore ]   [ # 38 ]
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VYAZ, I hate to keep butting heads with you but I couldnt disagree with you more. You need to look at this from a detached perspective not an emotional one. You are arguing that you don’t want to pay copays but the fact is that you are going to pay that money one way or another. Either you are going to pay the 20$ with each office visit or you are going to pay some equivalent amount that will just be hidden in your premiums but you are going to pay it. This is simple economics.

If you go to see a doctor now he may get paid $50 for your office visit. Usually $25 comes from the patient’s copay and the other $25 from the insurance company. If you eliminate the copay the doctor still needs to get paid and the insurance company is going to have to pay the entire $50. The insurance company’s actuaries will figure out how many times the average person sees a doctor in the course of a year (lets say its 3 times) and multiply that times the amount of the copay ($25) and your premium will now go up $75 for the year. You are still paying your copay you just dont see it. If you were someone who rarely went to the doctor you will now pay more than you did under the copay system. If you are an average patient you may break even and if you are a heavy user of medical services you will get a bit of a bargain.

This over simplifies the situation though. The fact is most people will actually end up paying more under the “no copay” system because any smart insurance actuary is going to realize that once the copays are eliminated the average number of doctor visits/year will likely rise perhaps to 4 or so. Therefor they will raise your premium by $100 per year. If you want to control costs you absolutely have to have some mechanism in place whereby the patient themselves plays an active role in limiting usage of health care services, and I don’t see any better way to do that than the copay system.

You suggested putting the entire responsibility on the government and the doctor but how would that work? In order for the doctor to know whether a patient has a real complaint or not he has to schedule an appointment and then spend time taking a history and examining the patient. Once that is done he has to charge a fee. When you go to see a doctor what you are paying for is the doctors time and the doctor cant give that up for free or he will go out of business. The only way to avoid that would be to have a very low paid individual interview the patient when they first call the office and that person would have to decide whether an office visit was necessary without involving the doctor in the decision, but do you really want a secretary telling a patient that their complaint isn’t worthy of the doctors time? That would surely be a recipe for disaster and no descent physician would ever agree to such an arrangement.

Patients need to take some personal responsibility ( something that seems to be sorely lacking in this country lately). If you have a runny nose for a day or two you dont need to see the doctor. If you have a moderate headache try Advil before you run to the the ER. These are the sorts of things that copays can prevent or reduce if they are structured correctly. there is no way that doctors or the government can stop that sort of misuse of the health system.

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Posted: 27 May 2012 01:22 PM   [ Ignore ]   [ # 39 ]
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zmullin - 27 May 2012 07:07 AM

why should I pay 50 dollars for a cup of coffee when some homeless fellow pays a nickel.

The reason I suggested a difference in copays is not a socialist one, its a matter of motivation or deterrence. If the purpose of using a copay is to limit the misuse of medical services it has to be a real deterrent. A $20 copay is not much of a deterrent to someone who makes $500,000/yr, but its an overwhelming deterrent to someone who’s weekly food budget is $50. For copays to really work well they should be based on income or preferably wealth other wise it will prevent poor people from seeking legitimate care and allow wealthy people to access lots of wasteful unnecessary care at every one else’s expense.

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Posted: 27 May 2012 03:35 PM   [ Ignore ]   [ # 40 ]
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One possible approach would be to fund the medical program as a part of a progressive income tax system (without all the deductions and exemptions the screw up the system at present).  Then charge the $20.00 co-pay for everyone.  While the co-pay would be more onerous to the poorer citizens, it would be compensated for by the wealthier ones paying appreciably more (through taxes) for services in general.

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Posted: 27 May 2012 05:11 PM   [ Ignore ]   [ # 41 ]
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zmullin - 23 May 2012 12:07 PM

Canada’s health care isnt sustainable though, is it unrealistic to expect some sort of co-pay. How many idiots go to emergancy room to sober up or over petty things.

Maybe they should make the idiots pay for the things they cause themselves or others.  But normal accidents or illnesses should be free.  That might involve some judgement on the part of the health care people though.  It shouldn’t be hard to tell when some clown is drunk.

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Posted: 27 May 2012 10:04 PM   [ Ignore ]   [ # 42 ]
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macgyver - 27 May 2012 01:22 PM
zmullin - 27 May 2012 07:07 AM

why should I pay 50 dollars for a cup of coffee when some homeless fellow pays a nickel.

The reason I suggested a difference in copays is not a socialist one, its a matter of motivation or deterrence. If the purpose of using a copay is to limit the misuse of medical services it has to be a real deterrent. A $20 copay is not much of a deterrent to someone who makes $500,000/yr, but its an overwhelming deterrent to someone who’s weekly food budget is $50. For copays to really work well they should be based on income or preferably wealth other wise it will prevent poor people from seeking legitimate care and allow wealthy people to access lots of wasteful unnecessary care at every one else’s expense.

In Finland, your moving violation fine is based on your income. Hefy income= hefty fine.

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Posted: 27 May 2012 11:16 PM   [ Ignore ]   [ # 43 ]
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macgyver - 27 May 2012 01:07 PM

You suggested putting the entire responsibility on the government and the doctor but how would that work? In order for the doctor to know whether a patient has a real complaint or not he has to schedule an appointment and then spend time taking a history and examining the patient.

...and what if the doctor makes an error? Doctors are human, sometimes they are tired, sometimes it is something they are unfamiliar with. There are many reasons they can make a mistake. They are not perfect. They will err on the side of being even more conservative, thus increasing costs more.

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Posted: 28 May 2012 06:23 AM   [ Ignore ]   [ # 44 ]
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asanta - 27 May 2012 11:16 PM
macgyver - 27 May 2012 01:07 PM

You suggested putting the entire responsibility on the government and the doctor but how would that work? In order for the doctor to know whether a patient has a real complaint or not he has to schedule an appointment and then spend time taking a history and examining the patient.

...and what if the doctor makes an error? Doctors are human, sometimes they are tired, sometimes it is something they are unfamiliar with. There are many reasons they can make a mistake. They are not perfect. They will err on the side of being even more conservative, thus increasing costs more.

To reply to Asanta and MacGeyver:  I agreed to co-pays.  I thought my suggestion was pretty solid.  $20 was an arbitrary figure. 
Mac, you are raising lot’s of questions which arise from the current system.  I’m suggesting a massively more simple system that will reduce administrative bloating.
To Asanta’s point, yes and reduce the doctor’s or nurse’s liability then with some new gov’t guidelines like I said.  This could ultimately end up with Mac’s pet of reducing malpractice suits-to a degree.  As long as everyone’s insured for free, and can get legitimate care for legitimate problems.
Gov’t guidelines based on triage-administratively.
The co-pay can be the same for everyone.  Just keep it cheap.  The savings and renumerations can come with triage. 
Doctors must re-learn to diagnose and turn hypochondriacs away-firmly!  The few items which slip through the cracks can be chalked up to the system, just as they are now.(ie.  under-diagnosis, or error…it happens now anyways to some degree.)

[ Edited: 28 May 2012 08:29 AM by VYAZMA ]
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Posted: 28 May 2012 03:40 PM   [ Ignore ]   [ # 45 ]
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Youre missing the point VYAZMA or more correctly you’ve missed several points.

There are several levels of triage. In most offices a secretary performs the initial triage which is to say she answers the call and has a simple set of instructions as to which types of complaints need to be seen immediately ( within an hour or less), which complaints need to be seen the same day but not immediately and which complaints are non-urgent. Because a secretary has zero medical training the triage protocol is simple and designed to err hugely on the side of caution. For example, every patient who calls with a complaint of having had chest pain within the past 24 hours must be seen within the hour or go to the ER, and if they are currently experiencing chest pain the doctor has to get on the phone immediately to determine if the patient can be seen in the office or if he/she should call EMS,no exceptions. The secretary is not allowed to ask follow up questions that might determine that the pain is just heartburn because he/she is not qualified to make that determination. her sole job is to determine how soon a patient needs to be seen based on minimal information and the protocol is designed to over react to complaints to avoid potentially fatal mistakes. Better safe than sorry.

Some facilities have a second level of traige being a nurse or a PA but in most small offices the second level is the doctor. In the example given above the doctor makes a quick determination on the phone and there is no charge Obviously the doctor can not get involved in every call. In fact for any practice to run efficiently the doctor should rarely get involved in triage.

There is no way that I can think of that the government could set up a better protocol that would allow low level employees to weed out “hypochondriacs”. Determining who has a legitimate complaint and who doesn’t is a difficult thing to do. It requires a lot of medical training and years of experience because a lot of the things people complain about can not be measured. How do you determine if someone’s back pain is real or not? A good doctor takes a detailed history and does and exam but in the end it becomes a diagnosis of exclusion. I may be able to tell from my evaluation that the problem is not a herniated disk and thereby avoid doing an MRI but I can’t determine if the pain is real or not with any exam or test.

If you are trying to eliminate the cost of the initial visit or even follow up visits there really isnt a good way to do that. The best you can hope from government intervention is that they may set up a uniform protocol whereby a patient has to meet certain criteria before they are allowed to have a given test. This is already done by insurance companies. I can;t order a CT scan without getting on the phone with an insurance company rep and explaining the case at which time they look on their computer and determine if the patient’s complaints fulfill the criteria. I dont know how effective this method is at reducing misuse of testing but it is already being done on nearly all commercial insurances. The country might be able to save money by requiring this procedure for medicare patients but as a physician I can tell you its an inefficient system that wastes the doctors time and delays treatment in many cases.

The other point that you keep mentioning is that you want to keep care free or cheap. Keep in mind someone always has to pay for this. It will never be free and isnt free anywhere in the world. If medical care isn’t paid for at the point of service ( like it was before insurance), or through premiums and copays ( as it mostly is now), then it will be paid for through taxes. It has to be funded somehow and by someone. The question is, what is the best way to fund it? I have said it before and I’ll say it again so there is no misunderstanding. I am strongly in favor of a single payor universal health care system, but any system that completely separates the consumer from the cost of medical care is doomed to overuse and spiraling costs. The consumer has to have some “skin in the game” so that they become a part of the decision making process and they think twice before pestering the doctor for a head CT they don’t need.

I can give you a personal anecdote that supports my opinion to some degree. Within my practice I have a number of patients who have a Medical Savings Account. The way an MSA works is that the employee has a high deductible ( About $3,000) health plan and along with that they have an employer funded MSA which is tax free money that is put in the account and can be used for any medical purpose. The amount of the MSA is usually enough to cover the deductible and it is funded each year even if the previous years contribution was not used. If it isnt used in a given year it rolls over to the next year and can accumulate. After a certain age the employee can withdraw the money for any purpose so if it isnt used it behaves a bit like an IRA. The cost of this plan to the employee is no different than it is with a traditional insurance plan but because there is the potential that the money in the MSA may someday be accessible to the employee they view it as THEIR money and they become protective of it. In all my years in practice I have to say that these are really the only patients who ever ask me whether a test really needs to be done or how much its going to cost. It rarely changes what I do because I have usually given both of those issues careful consideration before I recommend a test but if all patients had a financial interest (whether by way of an MSA type system or by copays )in these decisions I am fairly certain you would see less waste.

[ Edited: 28 May 2012 04:04 PM by macgyver ]
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