Obamacare and you

[DGuller]

 

[crazy canuck]

In your system, how are those 2 things different?

Patient walks in, says I think I have a brain doomah.

A price shopper would call up 4 CAT scan places and ask what they charge.

A gatekeeper would say you just have a headache, take some Advil.

And in the Canadian system a doctor would assess the patient, make a medical judgment as to whether any further inquiry was necessary, make a diagnosis and determine whether any further treatment was necessary.

Which is why GF asked his question.  Your system makes no sense to us.

[Admiral Yi]

FYI CC, the gatekeeper is an MD.

[crazy canuck]

FYI CC, the gatekeeper is an MD.

FYI there is a big difference between a medically trained person who is not the attending doctor acting as a gatekeeper and the attending doctor performing that function.

Everything I have read indicates that attending doctors in the US do not have the final decision as to the treatment their patient will recieve and who will provide that treatment as that is a question of the type of insurance coverage the patient has and the decisions of the "gatekeepers" to whom you refer.

[merithyn]

I just found out that "self-funded" companies - ie health insurance companies - are exempt from the exchanges.

Fucking "exemptions".

[Admiral Yi]

FYI there is a big difference between a medically trained person who is not the attending doctor acting as a gatekeeper and the attending doctor performing that function.

Everything I have read indicates that attending doctors in the US do not have the final decision as to the treatment their patient will recieve and who will provide that treatment as that is a question of the type of insurance coverage the patient has and the decisions of the "gatekeepers" to whom you refer.

In an HMO, your primary care physician is your gatekeeper.

Meri:  What does being "exempt from the exchanges" mean?

[crazy canuck]

I just found out that "self-funded" companies - ie health insurance companies - are exempt from the exchanges.

Fucking "exemptions".

What does that mean?

[OttoVonBismarck]

I agree that would be a silly way to create a single payor system.  Another of the efficiencies of a single payor system is, properly designed, it does away with a lot of administrative overhead.  There is no need to regulate referrals because the single payor regulates the cost for everyone.  Therefore it makes no sense for an administrator to be tasked with the job of deciding whether the patient should see doctor A or B.

I think the term single payer has always been awkward. I prefer the term "government payer system", because once you start using that it's understandable we're talking about something like providing for say roads or a military. Other services which are primarily provided by a system in which the government is the sole payer.

I agree with you that for healthcare a government payer system is most effective for many of the same reasons it is the most effective way to pay for roads and the military. However I must quibble, in a GP system the government does not regulate cost, they regulate price/reimbursement rate.

[merithyn]

It means that we're locked into whatever policy choices our company offers us.

Non-exempt company employees have the opportunity to seek out other companies and other plans.

[crazy canuck]

In an HMO, your primary care physician is your gatekeeper.

Based on what others have said you have to appoint someone to be that gatekeeper and if it turns out they are terrible then you have great difficulty moving to someone else.  But more fundamentally, in the HMO model there is a terrible conflict of interest because "your" doctor can only make decisions within the limited options funded by the HMO.

[merithyn]

In an HMO, your primary care physician is your gatekeeper.

Based on what others have said you have to appoint someone to be that gatekeeper and if it turns out they are terrible then you have great difficulty moving to someone else.  But more fundamentally, in the HMO model there is a terrible conflict of interest because "your" doctor can only make decisions within the limited options funded by the HMO.

It's pretty easy to change your primary. Usually it involves going on the insurance website and clicking a button.

And the doctor isn't tied to the HMO plan. She's just expected to do a once-over first to make sure that it's not something else before sending you on to a (much more expensive) specialist. I understood that that was common in Canada, as well.

[Berkut]

In an HMO, your primary care physician is your gatekeeper.

Based on what others have said you have to appoint someone to be that gatekeeper and if it turns out they are terrible then you have great difficulty moving to someone else.  But more fundamentally, in the HMO model there is a terrible conflict of interest because "your" doctor can only make decisions within the limited options funded by the HMO.

I am listening to this conversation, so to speak, and cannot help but wonder if every single HMO I've ever had is vastly better than the supposed norm, or whether your view of what the norm is is just completely out of whack with the reality.

I suspect that your basic disconnect is "based on what others have said..." view of how healthcare works in the US has little in common with how it actually works for most people with middle income health insurance.

I've never once had any problem getting any health care I needed. The only debates have ever been around who is paying for what and whether it falls under my co-pay or deductible, and even that has been very minor. The idea you seem to have that there are "limited options funded by the HMO" might be semantically accurate (I suppose there are some things my HMO won't cover, so technically the options are limited, but in reality I've never had any problem at all getting 100% of the medical services me and my family has needed, and that even includes some relatively expensive and rare genetic testing, for example) but practically incorrect.

[OttoVonBismarck]

FYI there is a big difference between a medically trained person who is not the attending doctor acting as a gatekeeper and the attending doctor performing that function.

Everything I have read indicates that attending doctors in the US do not have the final decision as to the treatment their patient will recieve and who will provide that treatment as that is a question of the type of insurance coverage the patient has and the decisions of the "gatekeepers" to whom you refer.

Yi is talking about HMOs. HMOs have various cost control mechanisms, and a properly run HMO in my opinion offers some of the best medical care in the world if they have a comprehensive and well managed organization of physicians. Kaiser Permanente to me, offers this level of care because they have thousands of doctors who actually work for them and they realize huge cost savings because there are no "provider referrals" and all this other business. Since everyone is a KP employee sending you to different practitioners is a breeze, it IMO realizes the best of all worlds in quality care, with none of the negatives you see in single payer systems. But it isn't perfect, it's still too expensive for the poor.

The "bad" HMOs, which is most of them, don't actually have everyone employed by the same organization. Instead there is a "virtual network" of providers who accept the HMO's coverage, and it tends to be a patchwork quilt of varying quality and painful restrictions and paper work to get anything covered.

But anyway, one of the ways in which HMOs save money is by having you pick a PCP--primary care physician. This is a person who is a "General Practitioner" or "Family Doctor" who serves as your starting point for all non-emergency care. Ex. under traditional American health insurance I find a cyst on my scalp, my first trip will probably be to a dermatologist who will look at it and diagnose it as most likely a benign cyst. He'll then schedule to either surgically remove it himself or refer me to a plastic surgeon depending on the location of the cyst and how tricky the removal will be.

Under an HMO, I would go to my PCP first, and would not be allowed to go straight to a specialist like a dermatologist. Then the PCP does a preliminary diagnosis and sends me to either a dermatologist or surgeon who can then look at it again and make their diagnosis, and who then will either remove it or schedule a removal with a third doctor. That sounds crazy, but where it saves money is when I think I might have a crazy heart/skin/brain/liver/etc problem and I rush to a specialist, and it ends up being mono or the flu, the PCP can stop the stupid train in the station. HMOs mostly do not work though, which must be understood.

[Admiral Yi]

I'm beginning to get the sneaking suspicion, based on CC's comments, that the entire Canadian system is a giant HMO.

Not that that's necessarily an evil thing. 

[The Brain]

Is the Keymaster an MD?