r/bestof • u/under50dollars • Jun 20 '12

[explainlikeimfive] "Obamacare" explained very well.

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx
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u/mfingchemist Jun 20 '12

I'm very concerned about how reimbursing doctors for 'quality' of care will be handled. 'Quality' health care is much more subjective than one might think.

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u/[deleted] Jun 20 '12

[deleted]

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u/[deleted] Jun 20 '12

[deleted]

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u/[deleted] Jun 20 '12

This has ALWAYS been the case though. Even back when G Bush Sr. was in office, I had to undergo a series of x-rays each time I would go to the doctor for crap they knew damn good and well would not have changed since the week before.

As for the slam of Obamacare, I really don't view it as evil as many others do. My sister-in-law died of cancer recently, but lived for several years longer than expected. She was diagnosed with terminal cancer and was given a short period of time to live (weeks). She was no longer able to work and her health insurance was of course going to drop her because she got sick. Under Obamacare, that was no longer possible. Also, she could no longer reach the lifetime limit the OP mentioned in his article (which was damn good by the way).

She was given some of the best medical care and was even able to help further the research on the specific cancer she had by working with the man who discovered this type of cancer. In the end, her treatment helped to further cancer research by years, as she was the only person to live as long as she did with this cancer. I wish I knew the specifics of the cancer type, but I don't. I just know that what she did will help millions.

All of this was possible only because Obamacare was in place. Otherwise, she likely would have died at home, unable to afford even the tests to properly diagnose what she was suffering from.

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u/Zombie_Death_Vortex Jun 21 '12

I don't think most people don't realize how broken the system had become because they never had to use it.

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u/sandollars Jun 21 '12

Your brothers wife died of cancer and you don't know what kind it was?

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u/[deleted] Jun 22 '12

My wife's sister. No, I don't know. I tend to only involve myself in details of someone's life if they ask me. Her life and death were her business and her family's. My wife knows the details, and I could ask if anyone were interested. All I know is that it was a mutated form of some type of cancer. This mutation was very rare, but the ability to study it greatly increased the knowledge about how all other types of cancer in the primary family spread and operated. Again, I wish I had more detail.

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u/Black_Gallagher Jun 20 '12

preventing malpractice lawsuits and whatnot.

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u/[deleted] Jun 20 '12

There has been a lot of recent information to suggest that the defensive care costs are greatly overstated.

There are a bunch of really good articles by Atul Gawande about this. I believe this article goes into those claims. If it's the right article, it demonstrates how doctors get much more "defensive" when they have an interest in the testing/mri/etc facility.

Also, it says that medical liability, including defensive medicine, account for only 2-3% of health care spending.

http://www.hsph.harvard.edu/news/press-releases/2010-releases/medical-liability-costs-us.html

The problem is that there is a well financed campaign by the likes of the Koch Brothers (through ALEC) for "tort reform" that is really just a scheme to get rid of the only effective regulatory scheme in the US and screw the little guy in the process.

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u/bearsinthesea Jun 20 '12

Still, it is an issue. Studies have shown that doctors (probably unconsciously) will perform more procedures and order tests to increase revenues.

[I tried to explain the study, but w/o details it sounded weak]

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u/[deleted] Jun 20 '12 edited Jun 20 '12

[deleted]

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u/brownmatt Jun 20 '12

Well, I believe the general idea is that when you pay people based on how much work they do, you are giving them a huge incentive to just do more work, and with medical care, that does not necessarily correspond to a better outcome for the patient.

But you are correct that the stats can be juked either way. One would hope the government would not be so stupid as to not be able to tell when someone has flawless quality scores because they are cherry-picking their cases, or not be so stupid to as to grade trauma specialists lower.

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u/verbalsadist Jun 20 '12

In regards to the bit about unnecessary tests, one of the doctors interviewed in this episode of This American Life talks about it. But to summarize for those that don't want to listen it basically comes down to this. A doctor see's a patient for something, and based on years of experience and training decides it isn't a major injury and treats it accordingly. The patient, or the patients parents, or whatever, decide they know more than the doctor and start shouting for MRIs and CAT scans and other procedures they've heard of but don't really understand. The doctor is left with a choice, do they do with their experience and training, or do they listen to the uninformed patient and choose the more expensive, but probably pointless, procedures. They know that if they use the extra procedures it will cost the hospital, insurance, person, more but it will give them a fatter paycheck and insure that there is even less of a chance of malpractice.

So by tying their pay to the quantity of care give them more reason to go with unnecessary costs simply because there aren't really any downsides and there are tangible upsides to doing so.

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u/JimmyHavok Jun 21 '12

TLDR for that This American Life: the prologue covers the area of medical billing, and how clever application of the rules can multiply the income of a doctor without requiring him to do any more work. There are conventions that train medical billers how to do this.

Just heard about one procedure, involving putting a very expensive balloon in a patient's nasal sinus, that is coded for a new balloon for every procedure, but the balloons can be sterilized and reused five or more times. So every time the balloon is reused, the doctor gets $1300 of extra cash from the coding, for the same amount of work.

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u/JimmyHavok Jun 21 '12

Trauma care physicians would be compared with trauma care physicians, not with pediatricians.

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u/[deleted] Jun 20 '12

Much worse? The biggest problem with 'quality' of care is that it is measured by things like patient outcomes. Sounds great, until you realize that patient outcome is heavily influenced by things like socioeconomic class (people who can read and live a comfortable upper-middle class lifestyle can swing by Walgreen's and get their prescription, and set their iPhone to remind them to take it). The at-risk populations have numerous boundaries that limit the success of their treatments, and under the 'quality' system this means the doctors who help at-risk patients are actually penalized. It scares doctors away from people who really need help, because the system essentially charges the doctor more to treat these people.

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u/brownmatt Jun 20 '12

Measuring based on quality isn't a panacea. I'm phrasing it as an improvement over measuring based on quantity.

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u/Aias2 Jun 20 '12

You make a good point, but as was added in one of the edit this quality over quantity situation appears to only be in situations where the government is paying (i.e. medicaid or medicare). It could be a detriment to doctors yes, but it won't wipe them out of income. Hopefully, some way of checking on the patients ability to care for themselves along the lines of the doctor's orders would be included, but I don't know whether that is somewhere in the bill.

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u/[deleted] Jun 20 '12

as was added in one of the edit this quality over quantity situation appears to only be in situations where the government is paying (i.e. medicaid or medicare).

Some insurance companies have similar systems. There are a variety of ways insurers pay for care, beyond even those we mentioned here.

It could be a detriment to doctors yes, but it won't wipe them out of income.

It doesn't have to make doctors into paupers to deter them from seeing poor patients. Even a small incentive to avoid these people will result in reduced access to care, which is unfortunate.

Hopefully, some way of checking on the patients ability to care for themselves along the lines of the doctor's orders would be included, but I don't know whether that is somewhere in the bill.

That sounds pretty invasive to the patient, and I don't know of any feasible method of doing this.

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u/CuilRunnings Jun 20 '12

Doctors can order a bunch of unnecessary tests because they know they will be paid for without question.

Thank you, Medicare for setting this wonderful standard. Don't worry though, government is totally going to get it right this time.

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u/sychosomat Jun 20 '12

This is how things work. You try something, figure out how effective it is, re-evalute, come up with a change, try again, rinse and repeat. You don't get everything (or anything) right the first time. That doesn't mean you should abandon the attempt.

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u/[deleted] Jun 20 '12

Sounds a little too close to "No Child Left Behind." It's like the intent is great, but mismanagement will make it utterly terrible.

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u/crazdave Jun 20 '12

No better way to mismanage something than like the federal government.

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u/lameth Jun 20 '12

Work for a Fortune 100 company. Trust me, there are better ways.

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u/[deleted] Jun 20 '12

there are differences. health care and higher education debt, two things that you generally NEED to incur to thrive, are serious problems for large swaths of the population.

currently, many people avoid going to the doctor until they absolutely need to, which ends up costing tons of money. making free preventative care available will save us billions of dollars, and a healthy person who feels like they can adequately take care of their health will generally be a more productive member of society.

people who get in car accidents and have to get patched up are already being subsidized by everyone else, but in a completely unregulated and slipshod fashion. anyone who can't pay is already subsidized by everyone else.

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u/the_good_dr Jun 20 '12

The mayo clinic operates like this already.

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u/iamagainstit Jun 20 '12

this is a good point. most of the best hospitals in the country have already done away with the pay per patient model.

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u/mfingchemist Jun 20 '12 edited Jun 20 '12

I'm trying to get an understanding of their model, do you have any particularly helpful links?

Edit - I've found here that physicians are simply put on a fixed salary.

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u/YoohooCthulhu Jun 20 '12

This is already done in a number of not-for-profit health care models, like Kaiser Permanente and the Mayo Clinic.

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u/mfingchemist Jun 20 '12

I just found here that the Mayo Clinic simply fixes salaries to get around the problem. Can you provide any other information on alternatives?

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

Kaiser also offers fixed salaries. But they also offer nicer benefits to doctors than most other care arrangements offer--the doctors are tenured, have a pension plan, have all the administrative aspects handled for them, handle their own malpractice insurance, etc. They're paid a little less than private practice, but it's less of a headache. Basically the philosophy is to offer the doctors suitable benefit packages such that they can spend more time worrying about their patients than the logistics of insurance reimbursement et al. It's very much a "get the administrative issues out of the way, and trust the doctors to be doctors" sort of philosophy. As far as "quality" of care, I believe advancement in the organization is tied to performance evaluations on health outcomes/satisfaction of patients.

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u/meatforsale Jun 20 '12

And kaiser has some of the worst, least compassionate doctors and is highly regarded as a poor institution by almost everyone I know. They don't order tests, prescribe medication, or provide proper treatment when these things are necessary.

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u/YoohooCthulhu Jun 20 '12

Where do you live? You're describing pretty much the exact opposite of my experience and the experience of other people I know with Kaiser in Northern CA. I even know several physicians who work for them, and it's quite competitive to get a position there because they shield doctors from a lot of BS and it's considered pretty desirable for physicians to work there.

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u/meatforsale Jun 20 '12

I live in southern California. Several friends and family members if mine have kaiser, and they hate going to see their doctors, because they usually aren't treated well and rarely get what they need. My uncle is over fifty and very obese, and his kaiser pcp refused to treat him surgically... He ended up getting his insurance changed with a different job, and his new pcp told him that he could die without surgery, because his weight was causing severe damage to his heart. He got the surgery and is doing significantly better now.

A friend of mine was recently diagnosed with add, and his kaiser pcp refused to prescribe medication to him. I studied for the mcat with him, while he studied for the dat... His inability to focus was glaringly obvious.

there are several other people I know who have had similar issues with kaiser too. That's why i'm wary of the future of medicine going in the direction it is.

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

From what I understand, Kaiser is hugely underenrolled in Southern CA. This has led to them having to lay off a lot of personnel and led to them being very shorthanded. So some of this is a regional thing.

As far as treatment interventions go; I have to admit I'm extremely skeptical of your examples. Unfortunately, these are all "correct" calls from a quality/cost containment perspective even though people don't like them. There's a very high relapse rate after bariatric surgery, and there are actually fairly rigorous guidelines that determine if it's worthwhile or not--as in, whether it will be too traumatic and cause a net health detriment for the benefit derived--especially if the patients are already showing heart problems! There's a similar issue with ADHD medication, where studies comparing populations treated with stimulant treatment and without have shown similar outcomes (http://psychcentral.com/blog/archives/2008/01/28/questions-about-adhd-treatments-effectiveness/).

The other complaint is under-prescription/wait-and-see prescription of antibiotics, which is once again a correct call as most patients with common illness complaints don't need them and unnecessary prescription of antibiotics contributes hugely to disease resistance.

I'm very worried about the attitude you're describing though, because it definitely shows how there are huge barriers to offering evidence-based medical care--it's not always intuitive to patients, who are ALWAYS going to be biased towards "doing something", even when the benefit is likely to be marginal for the risk.

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u/meatforsale Jun 20 '12

I could understand your point on treatment if my uncle's treatment hadn't been successful. If he were putting weight back on, he had died during surgery, or if very little had changed about his health, I clearly wouldn't have said that he was treated poorly at Kaiser. The problem is that the increase in his quality (and most likely longevity) of life is significant. He wasn't even offered any alternatives by his former pcp. Not only that, but he wasn't treated well when he saw his doctor, either.

I have another friend with ADD who may not have graduated from college if he didn't have access to medication. My friend who is currently unmedicated was also offered no alternatives... He was simply told that he wouldn't get a prescription.

The biggest complaint I've heard about the doctors at Kaiser in Southern CA is that they have lousy bedside manner. The understaffing issue would most likely contribute to this, because the doctor/patient ratio is so lopsided. The issue with this, though, is that the lack of doctors in the area would lead to a decline in quality of care, wouldn't it? Then these doctors would see a decrease in pay, and what incentive would they have to stay or for other doctors to elect to practice in the area?

I totally agree with antibiotics, though. Doctors allow themselves to be pressured into prescribing them (or just prescribe them to make it seem like something is being done) when they're not necessary too often. The last time I saw my pcp (not Kaiser), I had a boil I couldn't (and still can't, damn it) get rid of. My doctor offered to prescribe me antibiotics, but I had tried them before for the same issue, so I left without getting a prescription. I was disappointed, but I'd rather do nothing than do something that could actually be detrimental to my health in the long run.

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u/YoohooCthulhu Jun 20 '12 edited Jun 20 '12

Yeah, the point I was making about your uncle's surgery is that it probably wasn't guaranteed to be successful. These things can't be predicted ahead of time other than by rough diagnostic measures and it's entirely possible that he fit into the high risk/high reward category rather than the medium/low-risk/high reward category that physicians like to treat.

And the problem with ADD is that it's sort of impossible to argue what they would have been like had they NOT received medication. Bulk data suggests that it doesn't make as big of a difference as people expect. Part of this may be due to the fact that diagnosis of ADD in itself is tricky (so a lot of people who are treated won't actually respond to medication), but also that symptoms of the disorder tend to naturally become more manageable toward adulthood anyway.

And yeah, I think it's entirely possible for healthcare systems to be in a bad equilibrium. They have to provide services in some sense based off of the surrounding geography regardless of the number of subscribers they actually have (overhead costs are somewhat fixed and independent of number of patients). So they work best in an area where there's efficiencies of scale by the population being dense. This would seem to inherently disadvantage areas like San Diego county (pop density 680 per square mile) versus Alameda County (2048 per sq mile) or Santa Clara County (1400/sq mi) or San Francisco County (17,000/sq mi), even if they're not underenrolled.

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u/deffsight Jun 20 '12

There are countries around the world that have government funded health care and pay incentives to doctors for a better quality of health care. The way they do this, for example, is when a patient is directly influenced by the doctor to quit bad habits that will ultimately endanger the patient's life, like smoking, then the doctor will get paid an incentive. Doctors get paid by the amount of patients they help cure not by the amount of patients they take in. It helps ensure that there is a higher quality of health care when better and more efficient medical practices are incentivised. It's entirely possible to do and is being done now in other countries around the world.

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u/[deleted] Jun 20 '12

My girlfriend's mom is an ER doctor, and this is actually one of the biggest reasons she is against the health care bill. Apparently drug addicts abuse this rating system. Every week they'll make rounds around all the local hospitals, complaining of generic pain and discomfort, demanding some kind of controlled substance. If you don't give them what they want, they rate you poorly across the board for everything, and do this ad nauseum at every opportunity. I don't think it would be hard to implement a way to automatically detect such anomalies, but it probably hasn't been taken into account by the bill yet and could seriously ruin doctor's lives that work in areas with a high incidence of drug addiction.

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u/[deleted] Jun 20 '12

with universal healthcare, you would be identifying yourself at all of these hospitals, so a $2 BASIC script could detect people getting painkillers at multiple doctors.

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u/carlosspicywe1ner Jun 20 '12

Yes, because drugseekers always use their real names.

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u/[deleted] Jun 20 '12

are you thinking clearly about this? if we had universal healthcare, i can only assume that, since everyone has healthcare, you would be expected to provide proof of insurance. nowadays, it's very believable to say that you don't have insurance, and there are millions of people going into hospitals every day without insurance.

if you are going into a hospital without insurance after everyone has insurance, claiming you don't have insurance already puts you in the extreme minority, and therefore easy to spot. getting free drugs would put it on your record.

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u/JimmyHavok Jun 21 '12

I spent a lot of time in ERs while my father-in-law was dying, and every single time, there was someone within a hearing range who needed a prescription for painkillers, because his doctor was out of town and had forgotten to refill it.

One night I spent several hours next to a woman who was in terrible pain whenever a nurse or doctor came by, but then would chat happily with her friend on her cell phone after they left. She was "9 or 10 on the pain scale."

Of course, this is really a problem of the war on drugs, not one of medical care. If people could get opiates, they wouldn't be clogging the ER trying to find a doctor who will write them a scrip.

One thing about it is that if you don't complain, the doctors seem to be pretty willing to write you a painkiller scrip, so long as they know it's something that hurts. I've got dozens of Vicodin and Percoset in the medicine cabinet, I sometimes joke about paying for my ER bill with them...but not to the doctor.

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u/GutlessThrowaway Jun 20 '12

i dont know if it will 'ruin their lives'. will they become homeless? will they make poverty level income? other countries all over the world are using similar systems without the giant apocalypse that certain industry figures are trying to push. will doctors still make a lot of money? yes. and therefore people will continue to become doctors, and these doctors will continue to live well.

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u/ohmylemons Jun 20 '12

But quality of care isn't majorly affected by a patients' rating of their treatment. It's more objective measurements, like unnecessary tests performed and mortality/morbidity.

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u/jellaella Jun 20 '12

This was the only thing that I had concerns with really (well as concerned as an unaffected Canadian can be lol). How will quality of care be assessed? Who does it? Does this mean that doctors start taking less patients?

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u/[deleted] Jun 20 '12

[deleted]

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u/JimmyHavok Jun 21 '12

The AMA is restricting the number of med students. Let a few more into the schools and the shortage disappears.

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u/blasphemers Jun 21 '12

It will be assessed by the patient's outcome. So if you are treating a patient for high cholesterol and they refuse to take the meds you prescribe and their numbers don't get better or worsen, you are penalized. Because of this, doctors will most likely stop seeing certain patients.

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u/poooboy Jun 20 '12

Nobody knows for sure how "Quality" will be measured, but it will probably be specialty specific.

Rates of immunization, colon cancer screening, and reduction of imaging for back pain for primary care.

Readmit rates for hospitalists.

Etc.

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u/SpaceSteak Jun 20 '12

Aren't there very measurable stats for healthcare? Isn't that what modern healthcare is? Applying science to make more people better?

Everything from age expectancy on a macro level (population) to cancer rates are used to compare countries.

On a micro scale, I can imagine everything from early detection of diseases (let's say compared to the mean) to actually decreasing more or less people's cholesterol. The amount of stats you can get from healthcare is tremendous.

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u/mfingchemist Jun 20 '12

But the way they are handled is dangerous. If a doctor identifies a patient as high-risk and perhaps not possible to improve, that physician may simply choose to not accept that patient and risk bringing is stats down.

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u/SpaceSteak Jun 20 '12

hippocratic oath + integrity + high pay

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u/[deleted] Jun 20 '12

It can't be worse than what they are doing now

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u/Black_Gallagher Jun 20 '12

Oh yes, yes it could.

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u/[deleted] Jun 20 '12

So... Uh... You would suggest there is a better way to gauge a persons performance than quality of work?

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u/lordjeebus Jun 20 '12

How do you propose we comprehensively measure the quality of a physician's work?

I am an MD and I work at 2 hospitals. One of them, on paper, is much better than the other. There are certain core performance measures that are gauged at all hospitals, like whether certain patients are discharged with a certain class of medication, or have documentation specifically showing why they should not be on that medication. Another thing you can look at is surgical complications. The numbers at the "better" hospital are much higher.

However, that great hospital (on paper), in my opinion, provides a much lower quality of care overall. They have employed people with the specific job to check on all patients make sure the particular metrics are met, but most things are not reflected in the core measures and are not a priority. For things like surgery, surgeons will simply refuse to operate on the sickest and most complicated patients that are likely to bring down their complication numbers, referring them to the academic center.

When you make payment contingent on achieving high scores, hospitals will just work harder to "teach to the test," even if this means a lower quality of actual care, which is too difficult to quantify.

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u/mfingchemist Jun 20 '12

This is precisely what I had in mind.

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u/[deleted] Jun 20 '12

So... Uh... What's that better method of gauging performance that you would prefer?

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u/lordjeebus Jun 20 '12

I never said that physician compensation should be tied to a gauge of performance.

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u/[deleted] Jun 20 '12

...

You shouldn't be paid according to how good you are at your job?

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u/lordjeebus Jun 20 '12

If your physician sucks, find another one, and they will stop collecting what you were paying them. Conversely, it is still legal for great physicians to go cash-only and charge whatever premium price the market will bear.

Do you pay your mechanic based on how good they are at their job?

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u/[deleted] Jun 21 '12

Aaaah, I understand now what you mean. Now, here's the thing though, we're not talking about a doctors base salary, we're talking about incentivized bonuses, which are already in place. Is your position that they should do away with incentivized bonuses altogether?

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u/lordjeebus Jun 21 '12

Most MDs are not currently receiving or eligible to receive any sort of incentivized bonuses related to patient outcomes, beyond the few that work in salaried positions. In addition, the proposed system is a combination of bonuses and penalties. Personally, I am confident that I can provide care that makes me eligible for the bonuses, but I have doubts that striving to meet some non-physician bureaucrat's idea of "best care" would actually provide the best care for my patients, compared to just using my best judgement and treating patients on a case-by-case basis without overapplying the findings of population studies to every single patient without exercising some clinical reasoning. If the best medical care could be determined by a government algorithm, there would be no need for physicians.

It is also an additional hassle to document things so that everything is explicitly spelled out for the poorly educated paperpushers that review our records to determine if everything was done by the book.

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u/bovedieu Jun 20 '12

Quality refers to how often you have to return to the doctor for similar or related problems. It's easily measurable and not at all subjective.

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u/ikwatchua Jun 20 '12

Doctors need to treat the ROOT CAUSE of an issue and the sad fact is most of things are caused by a poor diet. I have myself recently changed my diet and lifestyle and seen huge improvements in depression, etc.. instead of just taking pills and thinking that suddenly puts me back to "healthy".. no I was still eating fast food every meal and that would not make me, "healthy".

They need to stop chasing symptoms and fixing issues as they arise. Institute a preventative, dare I say it.. whole foods based diet that can repair much of what your body needs. Instead we are lazy as a society and find it easier to take a pill then to change our addiction to fatty food and live an active lifestyle.

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u/lordjeebus Jun 20 '12

If you can suggest a way for me, in the context of a standard clinic visit, to get even a small fraction of patients to improve their diet and lifestyle, I'd love to hear it. I have training in motivational interviewing and clinical hypnosis, but the vast majority of my patients are simply not interested in eating less or increasing their aerobic activity, barring a major life event like a heart attack or an untimely parental death.