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:
Nov '11
Re: The End of Health Insurance?
DocJay
Anyone who can think ahead knows this leads to rationing with some very scary outcomes. Euthanasia centers seem quite likely.
Starting to move in that direction, with help from the Commission for Assisted Dying. (Is that an Orwellian name or what?)
Mar '11
Re: The End of Health Insurance?
This would be the same Dr Emanuel who got into an argument with Mrs Palin over her "death panels" comment a while back.
So, yes, he is in favor of rationing, and the inevitable "progress" towards Government healthcare, where the good citizen is, er, encouraged to reduce their burden on the State by living a healthy lifestyle and shuffling off this mortal coil quietly and quickly when the time comes.
Re: The End of Health Insurance?
The problem with ACOs is that economic incentives are inverted for actual sick people. With doctors and health systems being paid a fixed amount of money to keep me healthy, what happens when I fail to stay healthy--it happens, you know--and begin costing the system?
Under fee-for-service, my illness needs attention and providing me with care represents a profit opportunity. Under an insurance scheme, I enter into a financial contract to help me manage the cost of that possibility.
Under the ACO scenario, as long as I am healthy I am delighted--lots of unnecessary free stuff is directed my way to keep me voting right. Guess what? Since most people are healthy at any given time this works a treat for keeping politicians in power.
But once I become sick, I become a cost-center for the provider. Therefore, at the margin, there will be every incentive to under-treat, to delay and hope that I go elsewhere, or nature takes its course.
Edited on February 1, 2012 at 1:10amJul '10
Re: The End of Health Insurance?
This is what the original HMO brand was coined to convey decades ago, preventive medicine to avoid illness in the first place. It worked so brilliantly that two generations later they are running the same scam under a new acronym. Sadly, as any triage nurse can tell you, actual disease must be attended to before maybe someday illness. And the money they never budget in the expectation of lower claim rates from healthier patients ends up not being spent on patients in pain or with other urgent needs.
Been there, got the t-shirt. Took a refresher a few weeks ago when I took a neighbor to his HMO. He was seen three hours after his appointment time, 45 minutes from his home. The large waiting room was stuffed full of would be patients. Two bailed and went to the emergency room for minor injuries. My first direct sample in 20 years. Never again.
ObomneyLand will be worse, but its nothing to get upset about.
Re: The End of Health Insurance?
Point of personal privilege: DocJay, despite my earlier explanation of the design and function of the technology I am developing at my company, you persist in holding it up for ridicule as the signature example of Orwellian medicine of the future. You do this even though you have, in this instance, absolutely no idea what you are talking about.
I suggest you select from among the many real threats to individual liberty and privacy rather than making one up at my expense.
Mar '11
Re: The End of Health Insurance?
That pretty much describes the British and Canadian systems, which are clearly Dr Emanuel's utopia.
Edited on February 1, 2012 at 1:08amApr '11
Re: The End of Health Insurance?
Mendel
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? · 31 minutes ago
The regulatory definition of an ACO is actually defined in PPACA (Obamacare), but the general idea is a good one. The "A" stands for accountable, which means the providers are held accountable by a 3rd party, i.e. the insurer. The NYT columnist reached the complete opposite conclusion compared to the reality. There will be a greater need for quality analysis and financial metrics (both our job) with ACO's, not less. Even in a totally unregulated, free market situation, there will always be an insurance element to health care delivery. Whether the insurer will be private or government administered is another story.
May '10
Re: The End of Health Insurance?
DocJay, Richard, not only an advocate for socialized medicine, but a strong advocate of rationing and death panels.
May '11
Re: The End of Health Insurance?
ACOs make a profit by adopting strategies to recruit healthy patients in lieu of patients more likely to become ill. They also receive a larger piece of the pie by making all physicians salaried employees and thus control specialty referral. The days of the independent free standing outpatient surgery center or imaging center is near an end. Less choice leads to poorer care and more expensive care in the long run. If you have a physician today who knows your name and will coordinate your care in an emergency you are very lucky and you should do everything you can to reward that physician. That has become a rare circumstance and as a physician I think that is a terrible shame. I would not have gone into medicine if I knew this was the way it was going to end.
Jul '11
Re: The End of Health Insurance?
Dr. Savage, well I certainly could have been diplomatic in my choice of future intrusions in to our lives via medical technology. For that you have my apologies. I actually read everything about Proteus that I could find so I would not necessarily say I was uninformed. I found the work fascinating, and it would require quite a bastardized and malevolent alteration to end up where I placed it. If our world gets to that point we'll have more pressing things to fear than pharmaceutical compliance and metabolism rates.
By the way, that was a great analysis of ACO's flaws even with your dander up.
Jul '11
Re: The End of Health Insurance?
Southern Pessimist:
The days of the independent free standing outpatient surgery center or imaging center is near an end. Less choice leads to poorer care and more expensive care in the long run. If you have a physician today who knows your name and will coordinate your care in an emergency you are very lucky and you should do everything you can to reward that physician. That has become a rare circumstance and as a physician I think that is a terrible shame. I would not have gone into medicine if I knew this was the way it was going to end. · 6 minutes ago
So very sad and oh so true. My father, a Naval Anesthesiologist, warned me it would end bad but alas I have a stubborn streak. I have actively talked my almost 17 yr old out of it. He is joining the military. There may be more sanity for the soldier, even in times of war, than in our current medical structure.
Edited on February 1, 2012 at 2:17amSep '10
Re: The End of Health Insurance?
I won't add to the misery on this thread except to ask where Canadians will go for their first tier healthcare? Tacobell shouldn't be the only thing you run across the border to, or from.
Aug '10
Re: The End of Health Insurance?
Went to the Doctor today, think I caught a minor virus on the NR cruise (romnivirus) and it nagged and nagged. Hot and cold, sweaty and dry, I was whipsawed for 8 weeks. So since I hadn't been there this year a new questionnaire about lofty concepts of health goals was presented for my completion. I duly answered 66.6 % . The desired response date ? I thought my birthday five years hence was about right. Is this the new nu ! Dont want it- voting for anybodybut-^••^
Dec '10
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? · 7 hours ago
Kelly, how can you in the 1% live with yourselves when couch potatoes don't enjoy the same good heath that you do? Sure, you eat right and exercise, but that isn't really the point... it's just not fair. Your bottomless greed is the only reason you object to paying your fair share of public health expenses.
Re: The End of Health Insurance?
DocJay, many thanks. Apology accepted.
You make the essential point in your penultimate sentence, which I quote above. If we fail to reassert constitutionalism, we may in the end wind up governed by a police state without respect for person, property or privacy. At that point punitive uses of tax records, Internet search logs, Visa card bills, government electronic medical records--you name it--will be the visible manifestations of tyranny. And, yes, under such a regime my technology could also be misused, but only because of the lawless application of the law generally against the citizenry.
Nov '11
Re: The End of Health Insurance?
Ah, Ezekiel Emanuel. DocJay, you might enjoy this.
Jul '11
Re: The End of Health Insurance?
Hatchet buried for good Dr Savage, best of luck furthering your worthy endeavors. Mothership Greg , I took my oaths quite seriously and none of them included collectivism. That link was awful, what a horrible family those Emmanuels are.
Jan '12
Re: The End of Health Insurance?
"Accountable care organizations will shift the focus of medicine away from treating sickness and toward keeping patients healthy."
This is an excellent initiative in principle but merely extends the bathtub curve so we live longer. We will however all succumb to some malady which will terminate our existence in this life.
The net effect will be added medical costs to our lives which will mean we will have to transfer more wealth to the medical sector. To do that we may have to work for longer.
Perhaps we are moving to a situation where we pay more in medical expenses than in taxes.
Edited on February 1, 2012 at 2:59pmOct '11
Re: The End of Health Insurance?
Starve the Beast
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? · 7 hours ago
Kelly, how can you in the 1% live with yourselves when couch potatoes don't enjoy the same good heath that you do? Sure, you eat right and exercise, but that isn't really the point... it's just not fair. Your bottomless greed is the only reason you object to paying your fair share of public health expenses. · 11 hours ago
Shoot, you got me. Guilty as charged. Oh - and I'm a couch potato, for what it's worth. I only eat right.
Oct '11
Re: The End of Health Insurance?
Just to play devil's advocate here, an acute condition which shortens a patient's life would necessarily lower the costs of healthcare for that patient. Isn't it possible that an ACO would start responding to that sort of inverted incentive?