Off the record...health care is a mess. On the record...health care is a mess.

From: A State Medical Director for managed entitlement programs, Justin

We're a captive audience, stuck between the proverbial 'rock and a hard place'....

Big Pharma's making our drugs the most expensive in the world and getting Congress to protect their trade; it's a quid pro quo for support and TV adds in favor of health care reform.

We recently saw how "several prominent House Democrats" acknowledged, that they had "to give up a public option for insurance coverage in health care reform negotiations with the Senate." I don't know about you, but I hate to see serious reform reduced to politicians seeing what concessions they can extract for their vote.

Politics: the conduct of public affairs for private advantage.

- Ambrose Bierce

Then there's human nature showing what can happen if you're 'stuck.'—Docs ordering more visits when paid by the visit; referring more when not at risk for those referrals, especially the tough cases; reducing care when prospectively paid (e.g., capitation), and the worst example yet – an orthopedist telling a fibula fracture patient to use a boot and crutches or stay in bed for 3-6 weeks when he learned he would not get a surgical fee. (Yes, it really happened!)

From: The Executive Director of a large, academic group practice, Gilbert

Sent Feb. 27, 10:33 AM EST

Indeed, the patient is a captive audience and vulnerable, but there's hope---A lot of Federal (taxpayer) dollars are going to be spent on comparative effectiveness research over the next few years, and if there's a better use of my money I'm not aware of it. It is widely acknowledged that much of what we spend is wasted on unnecessary tests, advertising-driven consumer demand, unproven treatments and procedures that benefit device companies, specialists, and facility owners far more than patients.

It's also equally clear that reining in those costs is going to be incredibly difficult, because much of it occurs in the somewhat grey area between procedures that are clearly useless or harmful, and those that are undeniably appropriate. And while that grey area is where hundreds of billions are spent every year, it is also there where patients need real protection.

Justin's response, sent Feb. 28, 10:01 AM EST

Off the record...we are all to blame; On the record...we are all to blame.

Off the record...vested interests, including those who already seem to have their insurance issues taken care of (the people of Mass.), are not interested in fundamental change out of fear it will come at their expense (it will...insurance reforms, especially expansion to those who don't have it, costs money and surprisingly most of the money will come from people with current jobs and good health insurance).

On the record...same.

For example, with respect to insurers not paying for necessary supplies—my view depends on the details of the contract. I don't have enough information to say. I know that medical supplies are sometimes not even covered at all (in Child Health Plus, for example, I don't believe that spacers are a covered benefit because it is a 'supply' and only diabetic supplies are covered by legislation). Why? Because the folks who decide the benefits (your employer) didn't want to pay the extra premium for coverage of supplies (or, in the case of child health plus, the legislature/budget).

From: Jgk, responding Feb. 8, 2010 5:48 PM EST:

So, the patient is 'stuck' because the healthcare insurer forgot what business they're in.

Would it be right for an insurer to deny a spacer when that is vital for the administration of a beta2 agonist or ICS? How about a nebulizer mask and tubing for the same purpose? In other words, we should change the name of insurer to money launderer! Moreover, the employer is meddling in my health care insurance needs!

From: Fredrick (MD, PhD, JD)

Sent: Mar 30, 2010 4:53 PM

If a person buys an Indemnity insurance contract, he expects the insurer to pay for what the doctor orders. A failure to do so is Breach of Contract! For HMOs the problem is that the "discretion" allowed to the MBAs is frequently exploited to their own benefit, and "public opinion" notices that.

The solution to the problem is to remove medical discretion from the MBAs and their tame medical 'experts', and repose it in a disinterested non-profit body to make those efficacy calls, but always with an easy out for special cases.

But, quis custodiet ipsos custodes? If it is a government agency, as set up in the new health bill, people will note that the government is one of the largest payers. Can it be trusted not to try to minimize its costs? If it is a professional organization, can they be trusted to ignore the financial needs of their own practitioner members? And, what is the effect of commercial lobbying on the ultimate decisions?

I think this is the obvious place for a Science Court, where the pros and cons of a treatment or procedure are argued in Public by experts on each side, and decided by scientist-judges strictly vetted for absence of conflicts of interest.

Jeff, as I have argued before, they should not come up with one decision in each case, but with 2 rebuttable presumptions--an upper and lower level. Above the upper level, the procedure is rebuttably assumed to be proper; below the lower level, it is rebuttably presumed improper; and, between the levels, the doctors' decision is left undisturbed.

By "rebuttal", I mean that outside the middle range, the doctor must present evidence why in the particular patient the presumptions should not be applied. The nature of acceptable evidence should also be decided by the Science Courts. All their decisions should have Sunset provisions, to be sure that they are reviewed periodically.

As the saying goes, Justice must be SEEN to be done! Now, in this area, I don't think our existing institutions are capable of even reaching just decisions, much less ones that will carry conviction to the public that's ultimately paying the bills.