The End of Health Insurance?
An opinion piece from the N.Y. Times that details the evolution of HMO's in to Accountable Care Organizations or ACO's. Accountable care organizations will shift the focus of medicine away from treating sickness and toward keeping patients healthy. While these organizations when managed well really lower costs and provide better care, they also demand accountability from patients to a level where some of us would be pretty uncomfortable. The vast majority of people will actually like this system though since it not only provides a Medical Home but also focuses on avoidance of sparks rather than the full fire engine approach which we currently use.
OPINION | January 30, 2012
Ezekiel J. Emanuel: The End of Health Insurance Companies
By EZEKIEL J. EMANUEL and JEFFREY B. LIEBMAN
The article, written by non physicians, assumes somehow that physicians will actually be in control rather than bureaucratic folks. I doubt this supposition. I also believe that after Obama is re-elected that he will force this business model with the support of most Americans. The model does make sense medically, and better care for lower costs is a positive goal.
The issues that are ignored by this article and will be obfuscated by the government are many. The payers will be large companies and our government. To what level will those paying the bills have influence over your care? Will the harm of tort ever be addressed? How will invention in the areas of Pharma and technology proceed as these drive costs up?
Much more importantly, when the mandatory monitor in your heart signals your primary care masters that you've been non-compliant with your anti-hypertensive regime what are they going to do? Should they listen to your stories about fatiguing side effects combined with ED or send a tech to your house to administer daily involuntary injections. We're all in this together you know.
Edit. Richard Stewart has pointed out that Ezekiel Emmanuel is indeed a doctor. He is an M.D. Phd and is the brother of Rahm "sharp elbows" Emmanuel.
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Comments:
Oct '11
Re: The End of Health Insurance?
Speaking as someone who changed her diet about 2 years ago to one that is a bit out of the mainstream (I eat heart-healthy-saturated-fat and avoid grains and sugar), I want no part of this whatsoever.
How about a little freedom here?
Dec '10
Re: The End of Health Insurance?
He who pays the piper calls the tune. The flip side of liberty is responsibility. I can't expect the liberty to live on twinkies and not accept the responsibility to pay for the bypass. It makes sense that those paying for the heart failure should be in control of the twinkie supply as well.
On a side note: I just had a conversation with a very conservative friend who is frustrated enough with the current system to be tempted by socialized medicine. The outcomes may not be great, but at least they will be equal. It was a very strange conversation.
Aug '11
Re: The End of Health Insurance?
Everything is going according to plan!
Jul '11
Re: The End of Health Insurance?
Kelly B: Speaking as someone who changed her diet about 2 years ago to one that is a bit out of the mainstream (I eat heart-healthy-saturated-fat and avoid grains and sugar), I want no part of this whatsoever.
How about a little freedom here? · 21 minutes ago
I have a good diet and exercise but my healthy choices getting pooled with unhealthy ones does engender some resentment. That resentment in the hands of the government will lead to the food police and Lord knows what else. I'll go get some freedom fries tonight methinks, whilst I still can.
Oct '11
Re: The End of Health Insurance?
DocJay
Kelly B: Speaking as someone who changed her diet about 2 years ago to one that is a bit out of the mainstream (I eat heart-healthy-saturated-fat and avoid grains and sugar), I want no part of this whatsoever.
How about a little freedom here? · 21 minutes ago
I have a good diet and exercise but my healthy choices getting pooled with unhealthy ones does engender some resentment. That resentment in the hands of the government will lead to the food police and Lord knows what else. I'll go get some freedom fries tonight methinks, whilst I still can. · 1 minute ago
The whole shared-risk foundation of insurance makes me wish I had an easy path to working with a concierge doc, honestly - and some assurance that I could stick with that approach, rather than being forced back into the herd. But I'm not going to bother until the Supremes rule on the mandate and Obamacare.
Mar '11
Re: The End of Health Insurance?
Hey Mr. DJ,
thanks for the article and the commentary.
The background to this article is obviously the idea that the government will either be footing the bill directly or mandating a private entity to do the same. However, the principle that medical payments are based on entire patients and/or outcomes and not individual procedures is one that many free-market healthcare advocates also sponsor. Thus, it is important to keep in mind that the pitfalls of this type of care are not limited to a top-down system.
And pitfalls there are many. Whenever I read one of these proposals to reward doctors for preventing future costs I have a question for real doctors: how many doctor/hospital visits are actually preventable? Obviously people can try to quit smoking, lose weight, and take their medications as prescribed, but there is also a certain "$%?! happens" element to medicine that is unavoidable, no? How does this factor into these cost assessments?
Mar '11
Re: The End of Health Insurance?
Kelly B
DocJay
Kelly B:
The whole shared-risk foundation of insurance makes me wish I had an easy path to working with a concierge doc, honestly - and some assurance that I could stick with that approach, rather than being forced back into the herd. But I'm not going to bother until the Supremes rule on the mandate and Obamacare.
I agree with this sentiment completely, but that still leaves the question of what to do with people who, through no fault of their own, will incur medical costs so large that they or their families could never afford it. Either somebody else pays that bill, or that person is left to suffer.
Not trying to advocate for socialized medicine in any way, just sayin'.
Nov '11
Re: The End of Health Insurance?
Please don't yield that point! The outcomes are not equal. A government-run system doesn't remove the problem of scarce resources -- it means their distribution is driven by politics rather than the free market.
The way this often plays out in the UK is that if you are well-educated, articulate, and know how to create a fuss you will be taken care of (sooner or later). If you are poor, or on welfare, and especially if you are elderly, you are more likely to get the short end of the stick. The way the elderly are treated is appalling.
I can sympathize with your friend. Coming back to the U.S. and learning how to deal with insurance caused me much grief (not to mention money.) It was so much simpler in the UK -- essentially, you wait and do as you're told.
Oct '11
Re: The End of Health Insurance?
Mendel
Kelly B
DocJay
Kelly B:
The whole shared-risk foundation of insurance makes me wish I had an easy path to working with a concierge doc, honestly - and some assurance that I could stick with that approach, rather than being forced back into the herd. But I'm not going to bother until the Supremes rule on the mandate and Obamacare.
I agree with this sentiment completely, but that still leaves the question of what to do with people who, through no fault of their own, will incur medical costs so large that they or their families could never afford it. Either somebody else pays that bill, or that person is left to suffer.
Not trying to advocate for socialized medicine in any way, just sayin'. · 1 minute ago
My knee-jerk reaction is "Charity" - but in today's world, where the government stands in for charitable organizations in so many ways and all "donations" are extracted with the force of law, I don't know how we'd get the paradigm shifted back, honestly. Guess I'd also like to see what the market, operating unfettered, would do to the costs. I have no solution to that dilemma.
Jul '11
Re: The End of Health Insurance?
Leigh
Please don't yield that point! The outcomes are not equal. A government-run system doesn't remove the problem of scarce resources -- it means their distribution is driven by politics rather than the free market.
The way this often plays out in the UK is that if you are well-educated, articulate, and know how to create a fuss you will be taken care of (sooner or later). If you are poor, or on welfare, and especially if you are elderly, you are more likely to get the short end of the stick. The way the elderly are treated is appalling.
Anyone who can think ahead knows this leads to rationing with some very scary outcomes. Euthanasia centers seem quite likely.
The well off and the clever will always find methods of better care in any system. I just resent the ones where I pay for their care involuntarily.
Jul '11
Re: The End of Health Insurance?
Mendel
Kelly B
DocJay
Kelly B:
The whole shared-risk foundation of insurance makes me wish I had an easy path to working with a concierge doc, honestly - and some assurance that I could stick with that approach, rather than being forced back into the herd. But I'm not going to bother until the Supremes rule on the mandate and Obamacare.
I agree with this sentiment completely, but that still leaves the question of what to do with people who, through no fault of their own, will incur medical costs so large that they or their families could never afford it. Either somebody else pays that bill, or that person is left to suffer.
Not trying to advocate for socialized medicine in any way, just sayin'. · 14 minutes ago
There is a partial answer with very high deductible policies made relatively easy and cheap.
There is however, no answer to our overall plight that does not disrupt some sacred cows though. I do know our current Medicare/Medicaid system is non-sustainable. The solutions will vary from free market to crony capitalist to pure socialism though. Choose wisely.
Oct '11
Re: The End of Health Insurance?
Mendel: Hey Mr. DJ,
Whenever I read one of these proposals to reward doctors for preventing future costs I have a question for real doctors: how many doctor/hospital visits are actually preventable? Obviously people can try to quit smoking, lose weight, and take their medications as prescribed, but there is also a certain "$%?! happens" element to medicine that is unavoidable, no? How does this factor into these cost assessments? · 23 minutes ago
The other thing that worries me is that the recommendations for how to prevent future costs may be based on bad science (I'm no fan of the food pyramid, obviously). If some of that stuff is enforced as a precondition for affordable health coverage (on the private side) or mandated legally (on the socialized side) and it proves to be wrong, imagine all the consequences.
Mar '11
Re: The End of Health Insurance?
Kelly B
The other thing that worries me is that the recommendations for how to prevent future costs may be based on bad science (I'm no fan of the food pyramid, obviously). If some of that stuff is enforced as a precondition for affordable health coverage (on the private side) or mandated legally (on the socialized side) and it proves to be wrong, imagine all the consequences.
Actually, this could be a very good case for the complete privatization of these Accountable Care Organizations (meaning no government subsidies or regulation). In my experience, when it comes to new scientific findings, the private sector (especially big corportations) are much more weary of untested theories than either the government or individuals. If they jump on the wrong bandwagon (such as the latest fad diet or "food pyramid" or whatnot), it's their own millions which are on the line, not someone else's.
Sep '10
Re: The End of Health Insurance?
Every event comes with a diagnosis. There are quite a few suggested methods for classifying these diagnosis codes (everyone has their own research, natch). Typically in a savings analysis, so-called unavoidable visits (e.g. hit by a car) will be excluded. Obviously, there are plenty of diagnoses that fall into the grey area, and this is only the first of many considerations when it comes to designing an effective methodology for calculating ROI.
Rest assured, if a bureaucrat wants to "prove savings", he'll find a way.
May '10
Re: The End of Health Insurance?
If I'm not mistaken, Ezekiel Emmanuel is the MD brother of the infamous Rahm "Let-no-crisis-go-to-waste" Emmanuel, present hizzoner the Mayor of Chicago and former Obama White House Chief of Staff. What's more, Dr. Emmanuel has been a disgusting apologist for socialized medicine. Thus anything from this man's pen is instantly suspect, as far as I am concerned.
Feb '11
Re: The End of Health Insurance?
Leigh
Please don't yield that point! The outcomes are not equal. A government-run system doesn't remove the problem of scarce resources -- it means their distribution is driven by politics rather than the free market.
The way this often plays out in the UK is that if you are well-educated, articulate, and know how to create a fuss you will be taken care of (sooner or later). If you are poor, or on welfare, and especially if you are elderly, you are more likely to get the short end of the stick. The way the elderly are treated is appalling.
The US isn't like that, in my experience. Here, if you are on welfare or an illegal you get everything for free, no questions asked. If you have private health insurance you get to pay extra to cover all that, plus your own premiums, plus you get to jump through hoops or pay even more.
I'll spare everyone anecdotes, as I bet everyone else here has plenty of their own.
I'll add, however, that I think this demonstrates that your view that scarce resources are allocated by politics is correct, and already operating here.
Apr '11
Re: The End of Health Insurance?
I'm in the health insurance game and we're all about about ACO's. We came up with the idea. The NYT columnist isn't alone in being a person who kinda/sorta knows what an ACO is, then fills in the blanks with what they'd like it to be.
My favorite part of the article is the ridiculous non-sequitor: "Today, consumers have to choose among insurance plans with a bewildering array of copayments, deductibles and annual out of pocket maximums. In the A.C.O. model, consumers will choose a primary care physician." Who doesn't choose their physician? And what does that have to do with paying him?
That's like saying "chefs are presented with a bewildering array of ingredients and recipes, but their confusion will soon be over! Behold, we've remodeled the kitchen!"
Jul '11
Re: The End of Health Insurance?
Thanks, I semi-edited accordingly. Good catch and I agree completely.
Nov '11
Re: The End of Health Insurance?
Xennady
The US isn't like that, in my experience. Here, if you are on welfare or an illegal you get everything for free, no questions asked. If you have private health insurance you get to pay extra to cover all that, plus your own premiums, plus you get to jump through hoops or pay even more.
Oh, it's free in the UK all right. It just might take you a very long time to get it.
One of the scandals that erupted recently related to the neglect of the elderly in hospitals. In another, NHS trusts were caught delaying treatment hoping that patients would "remove themselves from the waiting list" -- in other words, give up and go private or else simply die. These are entirely believable.
No one suggests that it might have something to do with the fact that medical caregivers are accountable to bureaucrats and their innumerable "targets" -- not to the patient at all.
Mar '11
Re: The End of Health Insurance?
Zapp,
are ACOs a solution that would be viable in a less-regulated, non-subsidized healthcare market, or have they been designed specifically to meet the demands of government-mandated health insurance?