Obamacare and you

[crazy canuck]

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.

You may be right about the semantics.

Regarding regulating cost - they do that not just by regulated the tarrif by which physicians (and others) will be paid but they also have negotiating muscle with suppliers.  For example, if someone wants to sell tongue depressors  (not sure why that is the first thing that popped into my mind  )  they need to negotiate a price with the health authority.  All the doctors in private practice then get to piggyback on that price.  A doctor doesnt have to take advantage of the price.  If they think they can get a better product or better price they are free to try to do so but since the purchase adds to their overhead they are more likely to take the good rate negotiated by the health authority.  In this way you wont see the equivalent of a $500 screw driver in the Canadian system.

Another example is the cost of drugs and other medications.  The health authorities in Canada have become very smart at negotiating with suppliers so that they get good bulk discounts.  Something that would be impossible in a more fragmented marketplace.

The other significant way in which cost is controlled is through the direct funding model.  This is the biggest area of conflict within our system.  Health authorities prioritize where funding goes in order to try to keep in line with demands and attempt to keep costs in line with projected budgets.  The biggest weakness of our system is that if inefficient funding decisions are made it can, and does, result in wait list for procedures because there could be operating room time which is available and doctors available to do the procedure but the operating room is only funded to operate x amount of time.  If the problem gets too bad more funding is provided to clear up those backlogs.  However, we recognize that we do not have unlimited resources and so some amount of waiting is required.  But as I said, this is the #1 area of conflict in our system.

[crazy canuck]

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.

Interesting.  Under our system your first visit would be to your family doctor who would then assess what further treatment you require.  If the doctor determines you need a specialist then you will be referred directly to that specialist and your doctors office will help make that appointment.  Also the doctor would likely order some tests so that the specialist has the results for your visit.  Sounds like our system is very much like a well run HMO.

But I am curious.  What do you see as the downside to a single payor system?

[crazy canuck]

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

It is roughly equivalent to the very well run HMO he described.  But even then there are some differences that would make me uncomfortable with the HMO model.  I am not restricted to one access point to our system (the primary provider in an HMO model).  If I dont like my family doctor I can go to whomever I wish.  Or more likely, if I know that doctor X has a particular specialty as a primary care giver I can go to him for my treatment.

That is actually what I did with when diagnosed with my current condition.  I made a number of inquires and found the family doctor who best fit my needs.  As a result I have a different primary care doctor than the rest of my family who have another doctor who is best suited for their needs.

edit: another important factor is that my choice is not restricted to the employees of a particular HMO.  I have the whole system to choose from.

[merithyn]

It is roughly equivalent to the very well run HMO he described.  But even then there are some differences that would make me uncomfortable with the HMO model.  I am not restricted to one access point to our system (the primary provider in an HMO model).  If I dont like my family doctor I can go to whomever I wish.  Or more likely, if I know that doctor X has a particular specialty as a primary care giver I can go to him for my treatment.

That is actually what I did with when diagnosed with my current condition.  I made a number of inquires and found the family doctor who best fit my needs.  As a result I have a different primary care doctor than the rest of my family who have another doctor who is best suited for their needs.

Pretty much everything that you could do with an HMO.

[crazy canuck]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

[merithyn]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

The Canadian system allows for all doctors because it's a national program, and all doctors agree to a set charge. An HMO limits it to the doctors who sign a contract with them, agreeing to charge a specific charge.

Would your Canadian system cover a doctor in the US?

[crazy canuck]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

The Canadian system allows for all doctors because it's a national program, and all doctors agree to a set charge. An HMO limits it to the doctors who sign a contract with them, agreeing to charge a specific charge.

Yes, we are in agreement that I have a wider range to choose from.

Would your Canadian system cover a doctor in the US?

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

[merithyn]

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

Why would an insurance company cover the costs of a doctor not in their system, who has not agreed to their cost controls?

[crazy canuck]

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

Why would an insurance company cover the costs of a doctor not in their system, who has not agreed to their cost controls?

You have lost me Meri.  I made the point that I have more choice in doctors.  You seem to be agreeing with me but in an odd passive aggressive manner.

[Berkut]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

The Canadian system allows for all doctors because it's a national program, and all doctors agree to a set charge. An HMO limits it to the doctors who sign a contract with them, agreeing to charge a specific charge.

Yes, we are in agreement that I have a wider range to choose from.

Would your Canadian system cover a doctor in the US?

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

Her point is that you are making a distinction without a practical difference.

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

If in fact the Canadian system then creates a pool of less qualified doctors to begin with, the "greater choice" could actually be even less meaningful (I don't know if that is the case or not, of course).

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

[crazy canuck]

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

By definition "the bulk" of local doctors does not mean all local doctors. I can choose all local doctors and you cant.   No big mystery.

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

Do all HMOs have such a large pool to choose from?  If so why do I read posts complaining about lack of choice within HMOs?  Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

[merithyn]

Her point is that you are making a distinction without a practical difference.

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

If in fact the Canadian system then creates a pool of less qualified doctors to begin with, the "greater choice" could actually be even less meaningful (I don't know if that is the case or not, of course).

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

It's the same thing that you're talking about, CC, except that we have far more physicians and specialists in a smaller geographical region than you do. You may have quite a few in Vancouver, but I'd probably have twice that number to choose from in Chicago.

HMO doctor lists are regionally located. If I want to go outside my region, I have to pay extra for the privilege. If the specialist that could help you was located in Seattle, you would have had to do the same.

[merithyn]

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

By definition "the bulk" of local doctors does not mean all local doctors. I can choose all local doctors and you cant.   No big mystery.

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

Do all HMOs have such a large pool to choose from?  If so why do I read posts complaining about lack of choice within HMOs?  Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

It really seems like you're struggling to find some major flaw in the HMO system that just isn't a big deal, because you've found out that the Canadian system is the same thing.

[crazy canuck]

Her point is that you are making a distinction without a practical difference.

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

If in fact the Canadian system then creates a pool of less qualified doctors to begin with, the "greater choice" could actually be even less meaningful (I don't know if that is the case or not, of course).

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

It's the same thing that you're talking about, CC, except that we have far more physicians and specialists in a smaller geographical region than you do. You may have quite a few in Vancouver, but I'd probably have twice that number to choose from in Chicago.

HMO doctor lists are regionally located. If I want to go outside my region, I have to pay extra for the privilege. If the specialist that could help you was located in Seattle, you would have had to do the same.

The point is I wouldnt have to go to Seattle....

[merithyn]

The point is I wouldnt have to go to Seattle....

And I wouldn't have to go out of Chicago.