A companion blog, The Metacognition Project, has been created to focus specifically on metacognition and related consciousness processes. Newest essay on TMP: Goals and Problems, part two

Saturday, March 20, 2010

Delivery of Medical Services in the US to Remain a Travesty

The design of our medical services delivery system is devoted to unprotecting the wealth of those who need or will need health services. Since this is everyone, medical services delivery is the perfect place to make money, especially using the market insurance model.

Compare a simple and logical medical delivery system with the one we have now (really not changed by what is proposed in the present legislation). The pricing of medical services is a slightly separate issue to be considered later; for this argument, they are accepted as they are. All people would be taxed at a rate estimated by competent actuaries to maintain a fund from which services are paid and would be evaluated on a fixed schedule. The fund would be administered by either the federal government or the states (or using partnership agreements). Service provider groups negotiate compensation. All medical records are computerized. Services are invoiced by private providers to the single-payer fund. A fraud unit made up of doctors, lawyers and law enforcement would investigate suspicious medical claims by patients. A separate provider fraud unit would investigate suspicious claims by providers. Oversight committees would be established in state and federal government. Physicians, in consultation with their patients, would make decisions for treatment that would, only in exceptional circumstances, be subject to question based on empirically created algorithms.

In this model the numbers of doctors, nurses and other support would be determined by the rate of use of the system, i.e., the number of people that could be effectively seen and properly treated per day. This would necessarily result in changes in the rates of compensation for these service providers, but these amounts would be negotiated by all the stakeholders. Since a major component of this delivery model is the removal of the profit motive from medical services delivery – the designed-in goal would be to gain the greatest coverage for the least money collected from the tax payer – control systems for pricing and populating service components would be designed to use the best available information technology to replace market pricing and resource assigning methods. This would be, in fact, a primary purpose of such a design, since it has been these market processes that have led present medical delivery to be inefficient, inequitable and a major damaging influence on the democratic, social and economic enterprise.

Compare the above sketch of a plan with the present “system:” an individual gets a job; if the employer offers a “healthcare plan,” the employee can pay for it, often as much as ¼ of a typical income (the employee is paying the full cost of the plan; employer contributions are only tax gaming devices). The other option for the employee is an individual purchase of insurance coverage at near twice the amount of group plans. The insurance coverage is filled with rules, deductibles, co-pays, requirements of approvals, processes for denial of service. These rules can change without notice. The price can be changed without effective appeal. The consequence is that millions of people are denied the services that they pay for and millions more deny themselves services that they pay for because they cannot afford the deductibles and co-pays and can’t effectively fight the, often automatic, denials of payment by insurers.

If the individual’s job doesn’t offer a “health plan,” then the employee must buy individual insurance or go without. This means that he or she must pay for medical services on a fee for service basis, if they can find a provider who will see them. Then, in a perversion of market driven systems, they will have to pay more than an insured person for the same medical service; even though the provider has to do less paperwork, a major cost in the system.

Another option for this person is to apply for state-run Medicaid. If the person meets the income limitations this will let them into the medical service system. Providers may refuse to see Medicaid patients, however.

In both models for medical service delivery it is assumed that individuals cannot afford to pay, out of pocket, for possible and even likely medical services, especially for serious acute conditions or long-term illness. For this reason an insurance model is used. In the first model the insurance risk-pool is universal and administered by agencies designed to be neutral to medical procedures and evaluated on the competing goals of health quality and frugality (one can argue with the implementing of these goals, and should, in order to improve their functioning).

In the second model the insurance risk-pool is haphazard and uncertain resulting in a motive to remove people from it who are using services at costs approaching the premium payments. There are motives to make the coverage difficult to use by increasing co-pays, limits and deductibles and other rules. There are motives to select who will be covered or to remove people after they have paid into the pool, but who then will begin later on to use that coverage. There are large costs associated with the bureaucracy of claim denial and all of the machinations of paperwork, etc., that must be paid for by premiums. There are investors to be paid and high salaries for administrators sufficiently sociopathic to manage a money making system on the denial of medical services for other human beings (this is a nasty feedback design – a non-crazy person would not do the job and the people who will do the job will use it to get as much out of the system as they can). There are skyscrapers to be built; jet planes to buy; all the opulence required by the pissing-contest of corporate princedom; all from premiums paid by individuals to “insure” that they will receive medical services.

The Real Rant: The “healthcare bill” presently in congress doesn’t deal with the underlying issue in the difference between these two models. Everything in the description of the second model remains essentially the same except that the risk-pool becomes less haphazard and uncertain. If anything the situation gets worse since the monies available for Medicaid and Medicare are being reduced at both the state and federal level. The increase in the delivery of medical services will be minimal at best, the costs will continue to increase, though possibly (only possibly) at a slower rate. And the big issue: the market model will continue to control medical service delivery with all the negative consequences for the rest of our society. The promise that ‘if you like what you have, you can keep it’ is matched by the unspoken promise that ‘if you don’t like what you have, you can keep that too.’ This country will continue to spend twice as much as the other industrial countries for second best results and the corporate pissing-contest will go on at the cost of all the other services that could be funded by the wasted 1.1 trillion dollars a year (1/2 of the total medical expenditures per year) and the lost and injured lives.

There is only one reason to hope for this bill to be voted in. The mad men who have fought to maintain the present system, and won, shouldn’t get the further victory of being able to crow about their successful destruction of the effort. This is a weak gruel indeed.

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