dwivian | "rationing" in healthcare...

Are you not aware that all insurance companies already ration health care?

Insurance companies do no such thing. You are welcome to get health care without using an insurance company at all.

Insurance companies ration financial payments to the system. And, that's the same thing they have always done. My car insurance rations payments based on perceived costs and repair preferences. Health insurance does likewise.

I have dental insurance that WILL NOT PAY (at that emphasis, in fact) for an implant I will need shortly. They'd rather pay for three crowns worth of a bridge, at $1000 higher. Does this mean I won't get the implant? No. It means I'll pay for it. The healthcare was NOT rationed. Just the income source.

Absolutely. They ration at the door by denying coverage to anyone deemed to have a potentially expensive pre-existing condition.

On another note, I've never understood the rationale of small risk pools. Why don't they spread the "risk" evenly over *every* person insured by the company, rather than by employer?

That does not prohibit you from paying for it. Expensive, or otherwise. So, it's not rationing of the care, but of the money. I don't deny that money is being rationed, but the healthcare is available to anyone that will pay.

That's like saying "a house is available to anyone who will pay." Not everyone *can* pay.

I'm not really sure where you're going with this or even what prompted the post, but I have a feeling it's better left un-argued on my part.

I agree -- It's exactly the same statement, in fact. The distribution of scarce resources by a central agent is rationing. The distribution by ability to acquire is called commerce. Setting the price is a complex consideration -- I know if houses available in the US right now for $10,000. That's low enough that a large percentage of the population could acquire one (though it is not a home that many would desire). I do admit that a few people would be unable to buy even a house that cheap. I also know a few people don't want a house at all. As well, not everyone needs a 5br/4.5ba McMansion in a gated community. In fact, most people would find it isn't a particularly good fit. I also know that the same floorplan is a different price based on location and features. That's our healthcare, in a nutshell.

People are given expensive tests and procedures for various non-medical reasons (partial interests in the testing facility by doctors and hospitals, protection against malpractice suits, etc), and often the results aren't useful to the patient at all. Even the usual and customary cost for a procedure in Atlanta differs greatly from New York City, or Denver (personal experience, there). The overall cost of healthcare is a problem that could be solved in many ways. That will make it more available to end users.

I've funded clinics to make healthcare more cost effective. It was both a business decision, and a personal interest of mine. Unfortunately the experiement wasn't self-sustaining (Medicare payments are horribly slow, as is BCBS) and it failed after an unfortunately short time. But, with the right guidance, and the removal of the motivations that create price issues, the system will be much better.

Revision of the insurance industry would be a parallel event, and I can assure you that reducing their costs would be of interest to them. I can't say it would get more people covered, or more procedures done, but it would free up a lot of money that MIGHT do that.

"The distribution by ability to acquire is called commerce. "

I would like to point out that in commerce, the price of a commodity is known. If I want a Honda Civic, I can make some phone calls, and find different vendors who will sell me that product for a given price. Medicine doesn't work like that. Although, interestingly, vision correction surgery does. Some medical proceedures are complicated by the person who needs it, being incapactated when they need it, and not having any time to do comparison shopping.

Lots of medicine CAN be shopped around, but we don't do so because we have a culture of letting the insurance company handle it, or just not getting the procedure done at all.

I've priced things regularly for dental work. I've done similarly for my knee problems. But, good point -- if I was in the ER, I doubt I'd be interviewing doctors about the cost of removing a bullet in my liver.

But, that's true about any sudden-demand commercial need. If I want a Honda Civic RIGHT NOW, I will go to the nearest Honda dealership and buy one. I won't worry if I'm getting gouged, nor will I care if I have to pay list price. If I have time to wait, though, I can compare dealerships, and if necessary I can drive to nearby towns or states (as we did for my wife's new car) to get the best price.

Maybe medicine seems so 'in your face' because we, culturally, don't get things checked or fixed until they are seriously bad? Hm.... will have to think on that one.

Ho! Because I have a high deductible, I asked for estimate of my share on a planned "routine" preventive exam a couple months in advance. I was told $750 to $850, depending on lab work, by the physician's staff who supposedly consulted my insurance. The actual cost to me was $1963 & some odd cents. (The lab portion was $137.00) And guess who was accountable for the bad estimate? No one!

Good luck with that shopping around!

Had an estimate to take a limb down from over my roof. Estimate was $500. Actual cost, %2000. And, no surprise, the bad estimate wasn't going to be absorbed by the arborist, either. That happens with any estimate, in any industry.

Now, you CAN get a contract for work-for-pay (this is what the insurance companies do) and you don't have to pay any excess, but it isn't something the average patient thinks about. I've done it, though, and if the doctor balks, you don't want to do business with them (hey, if THEY don't trust their estimate, why should you?).

I quit the discussions when I was treated to "Pelosi and her flying monkeys" and "those damn immigrants." You have a better class of irritants than I do.

Oh my.... Nobody has brought immigrants into it at all with me. And, while Pelosi might have flying monkeys, that's mainly because they are an endangered species and need someone to help them re-establish colonies of viable genetic groups. :)

*snicker* Those poor flying monkeys, they could go like the dodo.

Yeah, I was hit with people not wanting their money to be taken away and given to those immigrants. Welfare queens were brought into it too.

Three guesses why I moved away from my hometown as soon as I could, first two don't count.

Ugh... I've actually met someone on welfare that had one more child because that got her into section-8 housing. So, I know there are people like that. I have also met someone who talks to aliens in the park, and someone that likes being beaten with straps for fun, someone that thinks water is wet, and someone that thinks it is reasonable to have chickens in their back yard. It takes all kinds, even those that are just a little off the edge, to be a population.

I once debated the immigrant population question. I started with asking the opposition if they would be comfortable with the income levels generated by cleaning toilets. They said no. I asked what they would have to be paid to take such a job. I was told $50/hr. I asked them if they would be willing to pay $150/hr to have toilets cleaned, to cover wage, materials, insurances [business and personal], etc. They said no.

Then I asked them who needed to do this job for less than they'd take. The silence was interesting.

"It takes all kinds,"

I'm not sure that's true, but it doesn't matter, as we do have all kinds.

Ah... yes. I bow to your wisdom. :)

I disagree. I think rationing-by-inaction is still rationing.

That violates the accepted definition -- rationing is an active function, not passive. If you want to flambe the vegetables like that, you could cause varigations in nachos by those attemping to telescope the conversation. Or, did my use of different definitions for existing terms not make sense?

There is no rationing by inaction. It simply cannot exist.

That said -- who is failing to act?

In rationing, resource is allocated by central agency, but when you get to the merchant with the eggs, subject to rationing, they still issue the eggs in line with the rationing scheme as indicated by, whatever mechanism tracks the rationing. How is that any different from a doctor saying "no money, no treatement?" It may be that there is a difference, but to me, it looks like a very convenient way to split hairs.

When I have seen the "we don't ration health care" arguement, it is an attempt to demonstrate that everyone has access to health care. That arguement falls on it's face when you look at the levels of health care the working poor actually get. If health care, and dental care, were available to those people, they would be getting better care than they do. No amount of semantics about what to call the mechanism, "rationing" vs "commerce" vs "unfair marketing practices" will change that.

My friend Stef had to wait until he was in his late 20's to get a hernia repaired that he had had since before he could walk. That may have been commerce rather than rationing, but there was no hernia repair surgery available to him until the condition became life threatening, and it was interesting coincidence that that just happened to be the same time that he got insurance coverage for the first time in his life. Not in his adult life, ever.

As I said at the top -- the net effect is the same. People grasp onto the rationing word because it has charged meaning, and incites fear. That is partly why I oppose the misuse of it.

I stand by my statement: everyone has access to health care, provided they can pay for it. That puts the onus of the care on the patient and doctor, to determine if the price that can be paid ever overlaps the price that the doctor wants to charge. Where they do, suddenly the healthcare can be performed, as with your friend Stef. I have worked with doctors to charge less, because I see the problem on that side. Just because care is available doesn't mean that people will use it. This, I have witnessed personally.

Had your friend won the lottery, inherited a great sum, or gotten one spectacular job that paid well but provided no insurance, the procedure still could have been accomplished. It just happened to be that the first thing that came along that could pay for it was insurance. But, had the cost of the care been reduced.... that might not have been the case. Other systems might have come along first.

This is why I feel that relying on insurance is a problem, because it isn't really a good system for making payments scheme happen, but it works for us because we're lazy, can't save worth a damn, and would prefer to foist our issues on others. :) But, it puts us at the mercy of the insurance business who then can decide what they think is a worthwhile procedure, and what isn't. You get companies that will pay for chiropractic and alternative medicines, but won't pay for technological advances in dental appliances (as is my case).

There never will exist a time when everyone has equal access to health care. By definition it is a scarce resource, and so there will be some means to distribute access, active or otherwise. Those with means will develop their own system (as in Canada) to bypass the delay created by bureaucracy, and the rest will use the common system as opportunities exist.

Cutting costs is the key. I have several ideas there (changes in medical training, distribution of labor within medicine and surgery, etc), but no matter what happens, we need to start with somehow making things affordable.

Everyone has access to health care, if they can afford it. Which is to say, many people don't have access to health care. Stef had to walk around with his intestines spilling into his scrotum when he exerted himself for over 20 years, including his entire childhood. When he did show up in the ER, his life was in danger, and he had a large sheet of necrotic tissue in his abdomen that complicated an otherwise fairly mundane hernia repair.

"it puts us at the mercy of the insurance business"

We are talking bout words, and there's an important one there. "Business" The profit mandate of a publicly held business ensures rising cost to the public.

"Cutting costs is the key."

A key, at the very least. Even if the hernia repair had been $500, Stef's mother probably would not have been able to afford it during his childhood. But I agree. Training is one of the parts of it. Doctors have to make a lot of money to justify all that medical school, but does a doctor really need all that training if they are going to end up as a podiatrist?

One of the examples that bugs me is psychiatists. Yes, they have a huge amount of training, including internal medicine and surgery. But that's not what most of their patients need. They need someone who knows the products currently on the market for ADD, anxiety, and depression. That's not 15 years of medical training being put to good use. But that huge underutilized medical background means that there is a six month wait around here to get a new patient appointment with a shrink, who is just going to ask "what's the problem?" and prescribe based on the patients self diagnosis.

"distribution of labor within medicine and surgery"

Hmm. I think I see what you mean, and yes. The surgeon needs to know where to cut, and how the body will react. The pharmacist needs to know what meds to put in to get which reaction. At times they will need to work closely as a team.

"we need to start with somehow making things affordable"

We are number one. We spend more money on medicine than anyone else in the world. We aren't number one in any of the results of spending all that money, but we are number one.

I'm sorry to say that the medical condition description of your friend seems to be an attempt to create sympathy in me, and it won't work because I'm immune to reality (I'm just not a sympathetic soul). A medical issue existed, and went for an extended period, because choices were made that the cost, as known, exceeded the ability to pay and afford other things that were desired (food and shelter come to mind). How bad it was isn't important, unless that can be used to gain advantage (as in the case of transplants). As an example:

I watched a show recently about a man who was covered in years worth of warts so bad he looked like he had bark instead of skin. He lived in a country where health care is rationed by the government, and he wasn't able to afford to go elsewhere, so he continued to suffer. A doctor took pity and did diagnosis and prescribed care, gratis, because he was an interesting case. His situation wasn't so dire as to cause his government to act, but it did move a doctor from the other side of the globe. Either way, the patient couldn't pay. Access wasn't limited by funds, but by the government and the sympathy of a specialist-physician.

An interesting caveat -- when the government was made aware that this man was being seen by a doctor from another country, he suddenly was picked up by ambulance, under great press fanfare, and taken to hospital to be treated. It also didn't escape my notice that, when there was a government to charge, the original doctor gave alternative treatment options at some serious cost, which was used to the benefit of patient and doctor alike. It was a very bitter realization, I'm sad to say.

So.... in a commerce system, the nature of the illness isn't the factor that drives the care; it's what you can afford. Cold and heartless, but true. The trick is to figure out how to do so at the right profit to create sustainability, while providing the maximum service (for marketability). Those are competing goals, alas.

I agree on the psychopharmocological problem -- I've seen that personally, too.

By distribution of labor, I meant to allow LRNs to do more, PAs to handle basic issues, and otherwise limit physicians to the hard problems. Bring back midwifes! That sort of thing. Good point on the pharm thing!

And, spending more than anyone else to get less care... not particularly affordable, is it? :) Imagine spreading that money out across more procedures because everything was suddenly 25% cheaper!

"the ability to pay and afford other things that were desired (food and shelter come to mind)"

desire: (vb)1. To long or hope for: exhibit or feel desire for 2.a. to express a wish for: REQUEST b.(Archaic) : to express a wish to: ASK 3. ( obsolete) : INVITE 4. (Archaic) to feel the loss of

Need: (n) 1. necessary duty: OBLIGATION 2.a. Lack of something requisite, desirable, or useful b. A physiological or psychological requirement for the well-being of an organism 3. a condition requiring supply or relief 4. lack of the means of subsistence: POVERTY

(vb) needed; needing; needs 1. To be needful or necessary 2. To be in want~ vt: to be in need of: REQUIRE~ ( verbal auxiliary) : the under necessity or obligation to

By employing imprecise diction, you downplay the severity and impossibility of the situation. The passive voice construction at the end works in tandem to create that result.

As far as the overall discussion, perhaps I will get into that in a bit, but I have to go get some things done. I am considering theming my 1102 class around the healthcare debateso this thread is particularly interesting to me... besides the interest for obvious reasons.

Shit! I forgot to cite! And I had it in mind to do so the whole time... that's at least 10 points off...

"Desire." Merriam-Webster’s Collegiate Dictionary. 10th ed. 2002.

"Need." Merriam-Webster’s Collegiate Dictionary. 10th ed. 2002.

The point of my statement was to acknowledge my awareness that things like food and shelter would take higher priority in a funding situation if a choice had to be made between them, but that I am also aware that many people place differing priority levels on things based on the immediacy of their import. That is, a surgery that seems 'necessary, but not right now' is going to fall behind not only food and shelter, but optional bills like electricity overages for climate control, non-basic foodstuffs, first-use garments, etc.

It is also a matter of interest that food and shelter can be had for no money, under the right circumstances (as can some medical procedures, come to think of it). So the desire to PAY for food and shelter differs from the desire for same. Not that it was my intent to make that point, but it does give me some sense of interest. :)

Healthcare is a finite resource and so some people get it and some don't. We can actively ration it or allow it to be rationed by the market via our inaction.

I think you're basically just splitting hairs here to no purpose. *shrug*

The purpose is to get people away from improper language. That's good enough for me. The term 'rationing' carries a lot of baggage (fear, for instance) that makes it a poor term. Never mind that it is inaccurate in this case.

The purpose is to get people away from improper language. That's good enough for me.

lol.

"Not very good, I am afraid. But now really, do not you think Udolpho the nicest book in the world?"

"The nicest--by which I suppose you mean the neatest. That must depend upon the binding."

"Henry," said Miss Tilney, "you are very impertinent. Miss Morland, he is treating you exactly as he does his sister. He is forever finding fault with me, for some incorrectness of language, and now he is taking the same liberty with you. The word 'nicest,' as you used it, did not suit him; and you had better change it as soon as you can, or we shall be overpowered with Johnson and Blair all the rest of the way."

"I am sure," cried Catherine, "I did not mean to say anything wrong; but it is a nice book, and why should not I call it so?"

"Very true," said Henry, "and this is a very nice day, and we are taking a very nice walk, and you are two very nice young ladies. Oh! It is a very nice word indeed! It does for everything. Originally perhaps it was applied only to express neatness, propriety, delicacy, or refinement--people were nice in their dress, in their sentiments, or their choice. But now every commendation on every subject is comprised in that one word."

"While, in fact," cried his sister, "it ought only to be applied to you, without any commendation at all. You are more nice than wise. Come, Miss Morland, let us leave him to meditate over our faults in the utmost propriety of diction, while we praise Udolpho in whatever terms we like best. * * * "

And, failed to make a point.

I think the point is that people won't be friends with you if you correct their word choice. At least, that seems to be what's happening in the excerpt.

lol. In fact, she marries Henry Tilney.

Man, I can't believe you guys are having that much trouble understanding the excerpt. I mean, ok, the prose is baroque, but it's not really THAT complicated. I guess I should have found some Dr. Seuss instead, or something.

Edited 2009-07-22 14:27 (UTC)

I guess it went right past you. oh well.

Quotes out of context bother me, as the discussion can be made to serve any end (I'm not a fan of it when done with scripture, either...Makes me a problematic person to a number of the bible thumpers in the area). I don't know if the tone should be seen as sarcastic, for instance, or if there is something stronger intended than is obvious from the selection. Context is key to the author's intent, and that is part of communication I hate to skip.

I had considered replying with a quote from "Through the Looking Glass", as it illustrates the need to reach common understanding of meaning:

"When I use a word," Humpty Dumpty said in a rather scornful tone," it means just what I choose it to mean -- neither more nor less."
"The question is," said Alice, "whether you can make words mean so many things."
"The question is," said Humpty Dumpty, "which is to be master -- that's all."

I'm in favor of words being held in common, so communication takes place. I hate when words are appropriated for new meanings, to create confusion and fear, and to manipulate people rather than inform.

In the quote you provided, the word was imprecise, but valid. In the discussion of healthcare the word 'rationing' is not valid, and thus the precision isn't at issue. It simply does NOT mean what people are using it to mean, and dilution of the definition only serves to sow additional confusion where it isn't needed.

Oh, wait... now I get it! By correcting the terms being used, I have forced you into a positionwhere you are going to have to marry me? I can see how that would be awkward....

close, but not quite ;)

What about "selecting" instead of "rationing?" By design, the health care system selects some people to receive certain care, and either denies certain care or makes it unattainable for others. It's not meant to serve everyone equally. It's selective.

A better term, yes.

Good word selection.

I'd say that at least some health care is rationed. Like the waiting lists for people who need organ transplants. I'm pretty sure it begins and ends with that.

As for the rest, you'd be right. Rationing isn't the appropriate term. That doesn't change the fact that being unable to pay for health care means you have little to no access to it.

Thinking about it, it's never once crossed my mind to use the term rationing in association with the health care system over all. The wording just doesn't make any sense.

I stand corrected -- organs for transplant are a perfect example of rationing in the system. And, I think you're right -- it's the only example I find from the healthcare side of things.

Thanks for that!

I agree with you, and I have to deal with VA medical.

"rationing" in healthcare...

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Medical shopping

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striving for correctness in both denotation and connotation

Re: striving for correctness in both denotation and connotation

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