Yet in recent decades, the rationale for concentrating so much care under one roof has diminished steadily. Many hospitals still exist in their current form largely because they are protected by regulation and favored by government payment policies, which effectively maintain the existing industrial structure, rather than encouraging innovation. Hospitals have sought to use the laws and regulations originally designed to serve patients to preserve their business model.
Hospitals are indeed required to provide emergency care to any walk-in patient, and this obligation is a meaningful public service. But how do we know whether the charitable benefit from this requirement justifies the social cost of expensive hospital care and poor quality? And again, the distortions caused by a reluctance to pay directly for health care—in this case, emergency medicine for the poor—are in large part to blame. Has anyone who believes this ever actually been to an emergency room?
My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded.
They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment? Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing.
But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal or incremental cost of serving ER patients. In a recent IRS survey of almost nonprofit hospitals, nearly 60 percent reported providing charity care equal to less than 5 percent of their total revenue, and about 20 percent reported providing less than 2 percent.
Might we be better off reforming hospitals, and allowing many of them to be eliminated by competition from specialty clinics? What amazed me most during five weeks in the ICU with my dad was the survival of paper and pen for medical instructions and histories. In that time, Dad was twice taken for surgical procedures intended for other patients fortunately interrupted both times by our intervention.
My dry cleaner uses a more elaborate system to track shirts than this hospital used to track treatment. Not every hospital relies on paper-based orders and charts, but most still do. Why has adoption of clinical information technology been so slow? Companies invest in IT to reduce their costs, reduce mistakes itself a form of cost-saving , and improve customer service.
But my father was not the customer; Medicare was. And although Medicare has experimented with new reimbursement approaches to drive better results, no centralized reimbursement system can be supple enough to address the many variables affecting the patient experience. Of course, one area of health-related IT has received substantial investment—billing. So much for the argument, often made, that privacy concerns or a lack of agreed-upon standards has prevented the development of clinical IT or electronic medical records; presumably, if lack of privacy or standards had hampered the digitization of health records, it also would have prevented the digitization of the accompanying bills.
To meet the needs of the government bureaucracy and insurance companies, most providers now bill on standardized electronic forms. For that matter, try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price. Several years later, when we were preparing for the birth of our second child, I requested the total cost of the delivery and related procedures from our hospital.
The answer: the hospital discussed price only with uninsured patients. What about my co-pay? They would discuss my potential co-pay only if I were applying for financial assistance. Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will.
Advocates for the uninsured complain that hospitals charge uninsured patients, on average, 2. Hospitals defend themselves by contending that they earn from uninsured patients only 25 percent of the amount they do from insured ones. Both statements appear to be true! How is this possible?
Well, hospitals bill according to their price lists, but provide large discounts to major insurers. Uninsured patients, however, pay according to how much of the bill the hospital believes they can afford which, on average, amounts to 25 percent of the amount paid by an insured patient. Nonetheless, whatever discount a hospital gives to an uninsured patient is entirely at its discretion—and is typically negotiated only after the fact.
Some uninsured patients have been driven into bankruptcy by hospital collections. But only a few states require institutions to make this sort of information public in a usable form for consumers. So while every city has numerous guidebooks with reviews of schools, restaurants, and spas, the public is frequently deprived of the necessary data to choose hospitals and other providers. One of the most widely held pieces of conventional wisdom about health care is that new technology is relentlessly driving up costs. Technology has transformed much of our daily lives, in almost all cases by adding quantity, speed, and quality while lowering costs.
So why is health care different? Why was the price so high? Most MRIs in this country are reimbursed by insurance or Medicare, and operate in the limited-competition, nontransparent world of insurance pricing. The surgery is seldom covered by insurance, and exists in the competitive economy typical of most other industries.
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So people who get LASIK surgery—or for that matter most cosmetic surgeries, dental procedures, or other mostly uninsured treatments—act like consumers. Many ads specify the quality of equipment being used and the performance record of the doctor, in addition to price. The history of LASIK fits well with the pattern of all capital-intensive services outside the health-insurance economy. So, as additional ophthalmologists in the neighborhood invest in LASIK equipment, the first provider can meet new competition by cutting price.
No business likes to compete solely on price, so most technology providers seek to add features and performance improvements to new generations of a machine—anything to keep their product from becoming a pure commodity. Their success depends on whether the consumers will pay enough for the new feature to justify its introduction. In most consumer industries, we can see this dynamic in action—observe how DVD players have moved in a few years from a high-priced luxury to a disposable commodity available at discount stores. DVD players have run out of new features for which customers will pay premium prices.
Perhaps MRIs have too. After a long run of high and stable prices, you can now find ads for discount MRIs. But because of the peculiar way we pay for health care, this downward price pressure on technology seems less vigorous. How well can insurance companies and government agencies judge the value of new features that tech suppliers introduce to keep prices up?
Rather than blaming technology for rising costs, we must ask if moral hazard and a lack of discipline in national health-care spending allows health-care companies to avoid the forces that make nonmedical technology so competitive. In , the U. Traditional reformers believe it is this rate of investment that has pushed up prices, rather than sustained high prices that have pushed up investment. As a result, many states now require hospitals to obtain a Certificate of Need before making a major equipment purchase.
In its own twisted way, this makes sense: moral hazard, driven by insurance, for years allowed providers to create enough demand to keep new MRI machines humming at any price. But Certificates of Need are just another Scotch-tape reform, an effort to maintain the current system by treating a symptom rather than the underlying disease. Technology is driving up the cost of health care for the same reason every other factor of care is driving up the cost—the absence of the forces that discipline and even drive down prices in the rest of our economy.
Only in the bizarre parallel universe of health care could limiting supply be seen as a sensible approach to keeping prices down. A wasteful insurance system; distorted incentives; a bias toward treatment; moral hazard; hidden costs and a lack of transparency; curbed competition; service to the wrong customer. These are the problems at the foundation of our health-care system, resulting in a slow rot and requiring more and more money just to keep the system from collapsing.
Instead it will put yet more patches on the walls of an edifice that is fundamentally unsound—and then build that edifice higher. A central feature of the reform plan is the expansion of comprehensive health insurance to most of the 46 million Americans who now lack private or public insurance. And if the history of previous attempts to expand the health safety net are any guide, that estimate will prove low. The reform plan will also feature a variety of centrally administered initiatives designed to reduce costs and improve quality.
These will likely include a major government investment to promote digitization of patient health records, an effort to collect information on best clinical practices, and changes in the way providers are paid, to better reward quality and deter wasteful spending. All of these initiatives have some theoretical appeal. And within the confines of the current system, all may do some good. But for the most part, they simply do not address the root causes of poor quality and runaway costs. Consider information technology, for instance.
Of course the health system could benefit from better use of IT. But in what other industry would an investment with such a massive annual return not be funded by the industry itself? Most of the benefits of the technology record portability, a reduction in costly and dangerous clinical errors would likely accrue to patients, not providers. In a consumer-facing industry, this alone would drive companies to make the investments to stay competitive.
I hope that whatever reform is finally enacted this fall works—preventing people from slipping through the cracks, raising the quality standard of the health-care industry, and delivering all this at acceptable cost. So I think we should at least begin to debate and think about larger reforms, and a different direction—if not for this round of reform, then for the next one.
Politics is, of course, the art of the possible. If our health-care crisis does not abate, the possibilities for reform may expand beyond their current, tight limits. The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care.
And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses including much end-of-life care funded by savings and credit; and massive, unpredictable expenses funded by insurance.
Many different steps could move us toward such a system. First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance.
All Americans would be insured against catastrophic illness, throughout their lives. Proposals for true catastrophic insurance usually founder on the definition of catastrophe. So much of the amount we now spend is dedicated to problems that are considered catastrophic, the argument goes, that a separate catastrophic system is pointless. Chronic conditions with expected annual costs above some lower threshold would also be covered.
We might consider other mechanisms to keep total costs down: the plan could be required to pay out no more in any year than its available premiums, for instance, with premium increases limited to the general rate of inflation. But the real key would be to restrict the coverage to true catastrophes—if this approach is to work, only a minority of us should ever be beneficiaries.
How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account—a vehicle that has existed, though in imperfect form, since Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions.
The income percentage required should rise over a working life, as wages and wealth typically do. All noncatastrophic care should eventually be funded out of HSAs. But account-holders should be allowed to withdraw money for any purpose, without penalty, once the funds exceed a ceiling established for each age, and at death any remaining money should be disbursed through inheritance.
This new approach would ensure that families put aside funds for future expenses, but would not force them to spend the funds only on health care. These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs; the government could lend directly, or provide guidelines for private lending. Catastrophic coverage should apply with no deductible for young people, but as people age and save, they should pay a steadily increasing deductible from their HSA, unless the HSA has been exhausted.
As a result, much end-of-life care would be paid through savings. Anyone with whom I discuss this approach has the same question: How am I supposed to be able to afford health care in this system?
Some experts worry that requiring people to pay directly for routine care would cause some to put off regular checkups. Today, insurance covers almost all health-care expenditures. The few consumers who pay from their pockets are simply an afterthought for most providers. Imagine how things might change if more people were buying their health care the way they buy anything else. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients.
In fact, as a result of our fraying insurance system, you can already see some nascent features of a consumer-centered system. It has also been slowly rolling out retail clinics for routine care such as physicals, blood work, and treatment for common ailments like strep throat. Many experts believe that the U. Medicare and private insurers have, to various degrees, moved toward or at least experimented with these sorts of payments, and are continuing to do so—but slowly, haltingly, and in the face of much obstruction by providers. For simplicity and predictability, many people will prefer to pay a fixed monthly or annual fee for primary or chronic care, and providers will move to serve that demand.
Likewise, what patient, when considering getting an artificial hip, would want to deal with a confusion of multiple bills from physicians, facilities, and physical therapists? I suspect we would see a rapid decline in the predominance of the fee-for-service model, making way for real innovation and choice in service plans and funding.
And the payment system would not be set by fiat; it would remain responsive to treatment breakthroughs and changes in consumer demand. Many consumers would be able to make many decisions, unaided, in such a system. How else might the system change? Technological innovation—which is now almost completely insensitive to costs, and which often takes the form of slightly improved treatments for much higher prices—would begin to concern itself with value, not just quality. Many innovations might drive prices down, not up. Convenient, lower-cost specialty centers might proliferate.
The need for unpaid indigent care would go away—everyone, recall, would have both catastrophic insurance and an HSA, funded entirely by the government when necessary—and with it much of the rationale for protecting hospitals against competition. Of course, none of this would happen overnight. And the government has an essential role to play in arming consumers with good information. We should establish a more comprehensive system of quality inspection of all providers, and publish all the findings. Safety and efficacy must remain the cornerstone of government licensing, but regulatory bias should favor competition and prevent incumbents from using red tape to forestall competition.
It would take a full generation to completely migrate from relying on Medicare to saving for late-life care; from Medicaid for the disadvantaged to catastrophic insurance and subsidized savings accounts. Such a transition would require the slow reduction of Medicare taxes, premiums, and benefit levels for those not yet eligible, and a corresponding slow ramp-up in HSAs. And the national catastrophic plan would need to start with much broader coverage and higher premiums than the ultimate goal, in order to fund the care needed today by our aging population.
Nonetheless, the benefits of a consumer-centered approach—lower costs for better service—should have early and large dividends for all of us throughout the period of transition. The earlier we start, the less a transition will ultimately cost. Many experts oppose the whole concept of a greater role for consumers in our health-care system. They worry that patients lack the necessary knowledge to be good consumers, that unscrupulous providers will take advantage of them, that they will overspend on low-benefit treatments and under-spend on high-benefit preventive care, and that such waste will leave some patients unable to afford highly beneficial care.
They are right, of course. Our current system features all of these problems already—as does the one the Obama reforms would create. Because health care is so complex and because each individual has a unique health profile, no system can be perfect. I believe my proposed approach passes two meaningful tests.
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It will do a better job than our current system of controlling prices, allocating resources, expanding access, and safeguarding quality. All of the health-care interest groups—hospitals, insurance companies, professional groups, pharmaceuticals, device manufacturers, even advocates for the poor—have a major stake in the current system. Overturning it would favor only the million of us who use the system and—whether we realize it or not—pay for it. Even the most casual effort to compare these prices to marginal costs or to the costs of off-the-shelf components demonstrates the absurdity of these numbers, but why should my mother care?
In-home medical and safety equipment are covered. Nurse Visits. Care after surgery or illness to recover at home. Pregnancy Care Nothing is more important than the health and well-being of you and your baby. That's why our plan benefits include: Choice of Doctor. Prenatal Visits. Care for you before your baby is born. Extra support to help you and your baby stay healthy.
Choice of Birth Center. Pick from hospitals across New York. Care for Conditions If you have special health care needs, you can count on us. Benefits include: Mental Health. Counseling and other treatments are covered. Case Management. If you qualify, get personal help managing health conditions. Exams, testing and supplies are covered.
Adult Day Care Companionship is important. Caregivers also benefit, knowing their loved one is well cared for and safe during the day. Adult day care can provide: Social connections and friendship. Bathing and personal care. You'll get a customized treatment plan and medicine to: Manage flare-ups.
Reduce symptoms. Let you or your child stay active. Case Management Do you or your child have a serious health problem or a high-risk pregnancy? If so, and you or your child qualifies, we offer case managers that can: Explain medical terms in plain language. Coordinate your doctor appointments. Provide your care team with your medical records. He or she will: Think beyond your medical needs. Make sure you have support at home. So you or your child can focus on getting better. Choice of Birth Center Where you have your baby is an important choice.
Your PCP is your main doctor for: Preventive care. Treatment if you are sick or injured. Referrals to specialists for certain conditions. Dental Care Checkups and emergency care are covered. Diabetic Supplies If you have diabetes, you may need insulin, needles, wipes and glucose strips. Our plan also steps up with services to help you manage your diabetes, including: Classes on keeping diabetes in control. Coordinating doctor care. Nutrition and diet. Durable Medical Equipment Your health and safety at home are important. This can include supplies like: Diabetic supplies.
Hospital beds. Wheelchairs or walkers. Emergency Response System If you are at risk for a fall or sudden illness, an emergency call system can really help. Grief Support A loss can take many different forms. We help you: Find a doctor for you and your baby. Learn resources for nutrition, fitness and safety. Get supplies, including breast pumps for nursing moms.businesspodden.com/libro-de-apolonio-con-la-historia.php
Health care in the United States - Wikipedia
Hearing Care Trouble hearing can affect your everyday life in many ways. Our plan covers: Exams, therapy and tests. Hearing aids. Home Meal Delivery Taking care of the basics, like cooking, can be hard to do yourself after an illness or sickness. In-Home Care After surgery or a serious illness you may need extra help with day-to-day tasks like cleaning, cooking or dressing. With approval, our plan covers: Medical equipment like hospital beds, walkers or wheelchairs.
Disposable medical supplies. In-home medical visit. Hospitalization This plan pays for all expenses related to a hospital stay, so you can rest and heal. Hospitalization coverage includes: Nursing care. Room and board. Supplies and equipment. Treatment and therapies. Diagnostic tests and exams. Medicines Our plan covers prescription drugs and refills with a small copayment.
And we make getting your medicine easy. You can fill your prescriptions at: Local pharmacies. Services that deliver right to your door. Member Services Sometimes you might need a little help understanding your health care options. We can also help you find: Home care providers. Dentists and vision providers. Adult day health centers.
Covered services include: All inpatient mental health and substance use disorder services including alcohol and substance use disorder. Most outpatient mental health services contact plan for specifics. Medicaid recipients who receive SSI or who are certified blind or disabled get mental health and substance use disorder services from any Medicaid provider by using their Medicaid Benefit Card. Detoxification services are covered by UnitedHealthcare Community Plan as a benefit.
No Copays You will not have a copayment for care and services covered by our plan, other than for prescription drugs. That means you will pay nothing for covered services, including: Preventive care. Annual checkups. Routine dental or vision care. You pay nothing for your child's care and services covered by our plan. Nurse Visit Sometimes you may need continued care after you leave the hospital or urgent care. If your health is at risk after a serious illness, surgery or injury, a nurse will visit you at home to: Provide medical care for you.
Answer your questions and concerns. Nutrition Coaching Healthy eating goes a long way to helping you stay at your best. A nutritionist can meet with you to review your eating habits and food choices. You'll come away with new ideas for: Making good choices for quick meals and snacks. Preparing healthy meals on a budget. Outpatient Services Knowing what's wrong and finding it early can make all the difference. Our plan covers: Labs and testing. X-rays, scans and other imaging. We'll help you get the information needed to help improve your health or be your best.
Personal Care Sometimes the basics are hard to do yourself after an illness or injury. If needed, we provide someone to help with: Dressing. All of your recommended prenatal clinical visits and tests are covered. At these visits, the clinic will: Make sure you and your baby are healthy. Explain what to expect at each stage of your pregnancy. Answer your questions. Quitting Tobacco You know the bad health effects of smoking. Residential Care After a serious illness, surgery or injury, you may need extra nursing and therapy.
Included are: Nursing home services. Help with activities of daily living. Physical, occupational and speech therapy. Respite Care Do you have family members or friends who care for you at home? Shots and Immunizations Routine shots help keep you healthy. So, our plan covers: Recommended shots and vaccines. Vision Care See life more clearly with routine eye exams and glasses, if needed. We also include: Prescription lenses. Medicaid approved frames. New eyeglasses every two years. This benefit is offered by March Vision Care. Well Visits Well visits with your doctor can help you stay healthy.
Preventive services include: Checkups for adults and children. Well-baby care. Care for women expecting a baby. Routine shots and tests. There are no copayments for preventive care. Member Resources. UnitedHealthcare Community Plan.
- Dorothy’s story (Individual stories from THE SWEETHEARTS, Book 4).
- Data Protection Choices.
- Aberdeenshire Folk Tales (Folk Tales: United Kingdom).
Notices and Bulletins Information on 3 new benefits for Medicaid children under Notice: New York State Department of Health has stated — Medicaid recipients should receive breast cancer surgery services at high volume facilities those facilities performing 30 or more mastectomy and lumpectomy procedures associated with a breast cancer diagnosis on average over a three-year period. Clinical Practice Guidelines UnitedHealthcare Community Plan has practice guidelines that help providers make healthcare decisions. Preventive Health Information Helpful information around preventative services.
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