Saturday, July 28, 2007
Sunday, July 22, 2007
Wednesday, July 11, 2007
On Medical Tourism
Quote:
Do you have any evidence that you'd like to put forward to support these claims? Are you certain that Canadians and Germans and the French and Swedes and Norwegians flock to the United States for every medical procedure?
For every medical procedure? No, of course not. But many Canadians do cross the border for treatment.
It is no secret that the density of medical practitioners and facilities is much higher in US counties within fifty miles of the Canadian border than elsewhere in the US. That's because a significant portion of their revenue is derived from Canadians. This is especially true of diagnostic services (MRI, CAT scanners, PET machines, etc.) Until a few years ago there were more MRI machines in the city of Philadelphia alone than in the entire country of Canada. That may still be the case for all I know... that figure is from 2003 and I haven't seen more recent ones. When I was passing through the small town of Mineral Wells, Texas, in the summer of 2005, I saw three clinics on the main drag alone whose signage stated they did MRI scans. I think it highly unlikely those were the only three MRI machines in the entire town. It's not like I was searching the whole town or anything -- I was just passing through on my way to somewhere else and happened to notice this fact. How many more MRI machines were there in that one small town alone that I don't know about? How many are there in the capital city of Saskatchewan?
Quote:
I, personally, don't know a single person who has ever had to leave Canada for any sort of treatment whatsoever.
I personally know several. But you reject anecdotal evidence, so I won't go into a lot of detail except to say one of them flew not to the US but to Germany to have her procedure done. She says it saved her life.
Then of course there was the widely reported case that ended up in front of the Quebec Supreme Court, where some guy whose name escapes me at the moment tried to recover from the Canadian government the costs of his travel and treatment to England (I think it was) because he would have had to wait some absurd amount of time to have it done in Canada, and it was a condition where time was of the essence. One of the lady judges on the Court wrote in her opinion (paraphrasing now since I don't have the decision in front of me at the moment) "Access to a waiting list is not the same thing as access to health care".
I see a lot of arguing over "efficiency" here. In medicine, "efficiency" is not a cut and dried concept. Are we talking dollars and cents efficiency or timeliness efficiency? Because if it is the latter, the US system wins hands down.
And even if we are talking dollars and cents, don't forget that in Canada, prescription drugs are not covered. So someone waiting a year and a half for an "elective" surgery (a knee operation or hip operation, say) could burn through thousands of dollars of pain medication waiting for the surgery. In the meantime, they might also be disabled to the point they cannot work properly, or even at all, which means extra costs to other government redistribution programs such as workman's compensation or disabilty benefits or unemployment insurance or whatever.
Then of course there is the whole quality of life issue -- how do you assign a dollar value to that? It's no picnic being semi-crippled and suffering chronic pain for months (or in some cases a year or more) on end.
It is this last reason more than any other that leads so many Canadians to cross the border and get themselves treatment immediately. Sure, they could wait and eventually get it done for "free" in Canada. Did you ever stop to think WHY so many prefer to spend the money to get fixed up NOW rather than wait months and save a couple thousand bucks? Do you think it is because these people are stupid or something? Remember, the folks who get this work done outside Canada never get reimbursed for their expenses -- they still pay the same taxes as everyone else. Yet they dig into their own pockets regardless. These people get socked twice -- they are paying US prices for the medical care they actually receive AND they are paying Canadian prices for that same care which was never delivered. But to these folks, it's worth it.
That fact (and yes, Gnote, it is a FACT) speaks volumes about the relative merits of the two systems.
Phred
Do you have any evidence that you'd like to put forward to support these claims? Are you certain that Canadians and Germans and the French and Swedes and Norwegians flock to the United States for every medical procedure?
For every medical procedure? No, of course not. But many Canadians do cross the border for treatment.
It is no secret that the density of medical practitioners and facilities is much higher in US counties within fifty miles of the Canadian border than elsewhere in the US. That's because a significant portion of their revenue is derived from Canadians. This is especially true of diagnostic services (MRI, CAT scanners, PET machines, etc.) Until a few years ago there were more MRI machines in the city of Philadelphia alone than in the entire country of Canada. That may still be the case for all I know... that figure is from 2003 and I haven't seen more recent ones. When I was passing through the small town of Mineral Wells, Texas, in the summer of 2005, I saw three clinics on the main drag alone whose signage stated they did MRI scans. I think it highly unlikely those were the only three MRI machines in the entire town. It's not like I was searching the whole town or anything -- I was just passing through on my way to somewhere else and happened to notice this fact. How many more MRI machines were there in that one small town alone that I don't know about? How many are there in the capital city of Saskatchewan?
Quote:
I, personally, don't know a single person who has ever had to leave Canada for any sort of treatment whatsoever.
I personally know several. But you reject anecdotal evidence, so I won't go into a lot of detail except to say one of them flew not to the US but to Germany to have her procedure done. She says it saved her life.
Then of course there was the widely reported case that ended up in front of the Quebec Supreme Court, where some guy whose name escapes me at the moment tried to recover from the Canadian government the costs of his travel and treatment to England (I think it was) because he would have had to wait some absurd amount of time to have it done in Canada, and it was a condition where time was of the essence. One of the lady judges on the Court wrote in her opinion (paraphrasing now since I don't have the decision in front of me at the moment) "Access to a waiting list is not the same thing as access to health care".
I see a lot of arguing over "efficiency" here. In medicine, "efficiency" is not a cut and dried concept. Are we talking dollars and cents efficiency or timeliness efficiency? Because if it is the latter, the US system wins hands down.
And even if we are talking dollars and cents, don't forget that in Canada, prescription drugs are not covered. So someone waiting a year and a half for an "elective" surgery (a knee operation or hip operation, say) could burn through thousands of dollars of pain medication waiting for the surgery. In the meantime, they might also be disabled to the point they cannot work properly, or even at all, which means extra costs to other government redistribution programs such as workman's compensation or disabilty benefits or unemployment insurance or whatever.
Then of course there is the whole quality of life issue -- how do you assign a dollar value to that? It's no picnic being semi-crippled and suffering chronic pain for months (or in some cases a year or more) on end.
It is this last reason more than any other that leads so many Canadians to cross the border and get themselves treatment immediately. Sure, they could wait and eventually get it done for "free" in Canada. Did you ever stop to think WHY so many prefer to spend the money to get fixed up NOW rather than wait months and save a couple thousand bucks? Do you think it is because these people are stupid or something? Remember, the folks who get this work done outside Canada never get reimbursed for their expenses -- they still pay the same taxes as everyone else. Yet they dig into their own pockets regardless. These people get socked twice -- they are paying US prices for the medical care they actually receive AND they are paying Canadian prices for that same care which was never delivered. But to these folks, it's worth it.
That fact (and yes, Gnote, it is a FACT) speaks volumes about the relative merits of the two systems.
Phred
Confronting The Socialists Halftruths
Quote:
In a profit driven system, there are substantial incentives for administrative build-up. Insurers invest millions in trying to deny their clients insurance. They hire investigation agencies to follow their clients around to see if they're actually hurt. They sue whenever they think they might be able to convince a court not to support their denial of claim. The most important issue, however, is that there are literally thousands of these companies doing the same thing. This is why administration costs are so ridiculously high.
Quite frankly, the issue of "Insurance companies fighting to deny coverage" is a myth. Does it happen? Absolutely, but nowhere near the amount that people reading Grisham novels want to believe. Remember that in a competitive market, quick and fair paying of claims is a huge factor in where agencies and insureds will place coverage.
Now, I can't speak to healthcare coverage, because I am in the P&C business, but I can tell you that what DOES happen a lot of the times is that people will assume they have coverage for things that they do not, and then seek to reclaim those costs. That's more a function of not reading their policy than insurance companies trying to "screw" their customers.
And again, I feel the need to remind you that very rarely will you have lawyers directly under the employ of an insurance company. Insurance companies will generally contract panel councils, and many insurance companies use the same law firms.
Quote:
This seems to be a uniquely American problem. Unless changes are made to your legal system, its unlikely that this would ever be solved under any system.
I absolutely agree with you, which is why I suggest that a big factor in removing these costs is to modify the way that torts are handled.
Quote:
This, however, does not change the fact that administration costs would fall substantially if you switched to a single-payer system.
Of course it does! Same population will, generally, require the same amount of manpower to file claims, determine scope of coverage, underwrite, etc. All you'd be doing is bring it under one umbrella. 10 underwriters doing the same amount of work is going to cost the same whether they are working for 2 companies or 10.
Quote:
You wouldn't have near as many lawyers or near as much administrative redundancy.
The only reason that the number of lawyers would reduce is if the number of suits is reduced. I don't see how nationalizing this will decrease the number of claims in the slightest.
Quote:
I'm not talking about insurance claims, I'm talking about lawsuits.
Um, in liability coverage, lawsuits ARE claims. Lawyers are almost exclusively dealt with through a claims department.
Quote:
Everyone in America with a brain knows that they need some sort of socialized, universal health insurance system
Excuse me? Did you just suggest that I don't have a brain?
In a profit driven system, there are substantial incentives for administrative build-up. Insurers invest millions in trying to deny their clients insurance. They hire investigation agencies to follow their clients around to see if they're actually hurt. They sue whenever they think they might be able to convince a court not to support their denial of claim. The most important issue, however, is that there are literally thousands of these companies doing the same thing. This is why administration costs are so ridiculously high.
Quite frankly, the issue of "Insurance companies fighting to deny coverage" is a myth. Does it happen? Absolutely, but nowhere near the amount that people reading Grisham novels want to believe. Remember that in a competitive market, quick and fair paying of claims is a huge factor in where agencies and insureds will place coverage.
Now, I can't speak to healthcare coverage, because I am in the P&C business, but I can tell you that what DOES happen a lot of the times is that people will assume they have coverage for things that they do not, and then seek to reclaim those costs. That's more a function of not reading their policy than insurance companies trying to "screw" their customers.
And again, I feel the need to remind you that very rarely will you have lawyers directly under the employ of an insurance company. Insurance companies will generally contract panel councils, and many insurance companies use the same law firms.
Quote:
This seems to be a uniquely American problem. Unless changes are made to your legal system, its unlikely that this would ever be solved under any system.
I absolutely agree with you, which is why I suggest that a big factor in removing these costs is to modify the way that torts are handled.
Quote:
This, however, does not change the fact that administration costs would fall substantially if you switched to a single-payer system.
Of course it does! Same population will, generally, require the same amount of manpower to file claims, determine scope of coverage, underwrite, etc. All you'd be doing is bring it under one umbrella. 10 underwriters doing the same amount of work is going to cost the same whether they are working for 2 companies or 10.
Quote:
You wouldn't have near as many lawyers or near as much administrative redundancy.
The only reason that the number of lawyers would reduce is if the number of suits is reduced. I don't see how nationalizing this will decrease the number of claims in the slightest.
Quote:
I'm not talking about insurance claims, I'm talking about lawsuits.
Um, in liability coverage, lawsuits ARE claims. Lawyers are almost exclusively dealt with through a claims department.
Quote:
Everyone in America with a brain knows that they need some sort of socialized, universal health insurance system
Excuse me? Did you just suggest that I don't have a brain?
More Q&A on socialized health care
Anyway:
Gnote wrote:
When there is competition in an insurance system, there will always be lawyers.
There are always going to be lawyers, period. Nationalizing one industry is not going to stop Tort cases, nor will it even begin to lower the costs of lawyer fees (especially if those lawyers continue to work on a contingency). All nationalizing it will do is mask those costs by distributing it over a wider base. I prefer to control the costs in the first place.
Quote:
I'm not trying to demonize lawyers (not that I wouldn't have reason to). I'm simply stating that where competition exists in an insurance market, there will always be someone to sue. Patients suing the insurer, insurers suing patients, doctors suing insurers, insurers suing doctors, insurers suing the government, and the list goes on and on.
You forgot the single biggest market: Patients suing doctors. That's precisely why Doctors carry malpractice and liability insurance (which, to the best of my knowledge, we are not suggesting to nationalize), and a SIGNIFICANT reason that the cost of healthcare has skyrocketed. Are you honestly suggesting these kinds of suits would dissapear by nationalizing it? The only way that would be true is if you blanket the industry with sovereign immunity, which doesn't solve the problem at all, it just makes it impossible to seek retribution.
Quote:
Then you need secretaries for the lawyers - hell, you probably need a warehouse just to store all of the files
There is nothing to suggest that this would change in the slightest just by nationalizing the industry. You'd still have all the above claim scenarios, with equally many lawyers.
Quote:
Every insurance company needs an entire department dedicated to processing the latest lawsuit.
Yes, it's called "Claims". It'd be hard to run an insurance company with no department to determine coverage and claim processing.
Quote:
These are just some of the ways that administration snowballs in a multi-payer system.
These aren't unique to a multi-payer system, they are inherant in any system that attempts to pool risk. It's 100% downright false to assume that malpractice litigation (and, subsequently, lawyers working on a contingency basis) would decrease simply because we nationalize the healthcare industry.
VForVendetta wrote:
Also, these private pharmceutical companies could corrupt the health care system as well by buying off doctors and attempting to establish monopolies while preventing cheaper, more efficient drugs from entering the market.
And what you seem to be unable to grasp is that what you just describe is a function of government intervention. What's the most effective way for a company to prevent drugs from hitting the market? Establishing a patent and limiting the supply through government intervenmtion. That's precisely what I am saying: the pharmaceutical companies have been granted too much power, but that power can only come through subsidies, tax breaks, patents, and the like via the government. You don't see Advil trying to get Tylonol taken off the shelves, do you? Why? Because they are generic ibuprofen drugs that are OTC and without a patent. They are readily available in any corner store in the US, and NOBODY complains that Tylonol or NyQuil is Price Gouging. Without the interference in the market forces that the government inherantly represents, competition drives the price down.
andres wrote:
If the government payed for everyone's bills, then the system would already be socialized and the cost of healthcare in the US would fall.
They wouldn't fall, they would be masked and distributed. Big difference.
exergenic wrote:
One of the reasons that a private health insurance market will consistently fail that has not yet been mentioned in this thread (if I have read it correctly) is the natural propensity toward information asymmetry. People generally know more about their medical history and illness trends within their family than insurers, and may choose not to disclose this information. Firms are at an immediate disadvantage, and over time must increase premiums.
That's why Underwriters generally re-assess a policy every year, taking in to consideration claim history, health, age, and several other factors. Over time, that premium should adequately reflect the risk that customer represents (actually, it might be significantly lower if the company is operating at an underwriting loss due to competition.) Risk analysis is a big part of the insurance industry, and nationalizing it essentially eliminates that sector, which I find to be more than a bit troubling.
exergenic wrote:
This is why Singapore proves to be such an interesting case study. At birth each Singaporean is issued a health account into which money is deposited each year by the government. The incentives system here is obvious, and there is some flexibility in severe cases where medical costs are necessarily exorbitant.
That's interesting, I had never heard of that.
Gnote wrote:
When there is competition in an insurance system, there will always be lawyers.
There are always going to be lawyers, period. Nationalizing one industry is not going to stop Tort cases, nor will it even begin to lower the costs of lawyer fees (especially if those lawyers continue to work on a contingency). All nationalizing it will do is mask those costs by distributing it over a wider base. I prefer to control the costs in the first place.
Quote:
I'm not trying to demonize lawyers (not that I wouldn't have reason to). I'm simply stating that where competition exists in an insurance market, there will always be someone to sue. Patients suing the insurer, insurers suing patients, doctors suing insurers, insurers suing doctors, insurers suing the government, and the list goes on and on.
You forgot the single biggest market: Patients suing doctors. That's precisely why Doctors carry malpractice and liability insurance (which, to the best of my knowledge, we are not suggesting to nationalize), and a SIGNIFICANT reason that the cost of healthcare has skyrocketed. Are you honestly suggesting these kinds of suits would dissapear by nationalizing it? The only way that would be true is if you blanket the industry with sovereign immunity, which doesn't solve the problem at all, it just makes it impossible to seek retribution.
Quote:
Then you need secretaries for the lawyers - hell, you probably need a warehouse just to store all of the files
There is nothing to suggest that this would change in the slightest just by nationalizing the industry. You'd still have all the above claim scenarios, with equally many lawyers.
Quote:
Every insurance company needs an entire department dedicated to processing the latest lawsuit.
Yes, it's called "Claims". It'd be hard to run an insurance company with no department to determine coverage and claim processing.
Quote:
These are just some of the ways that administration snowballs in a multi-payer system.
These aren't unique to a multi-payer system, they are inherant in any system that attempts to pool risk. It's 100% downright false to assume that malpractice litigation (and, subsequently, lawyers working on a contingency basis) would decrease simply because we nationalize the healthcare industry.
VForVendetta wrote:
Also, these private pharmceutical companies could corrupt the health care system as well by buying off doctors and attempting to establish monopolies while preventing cheaper, more efficient drugs from entering the market.
And what you seem to be unable to grasp is that what you just describe is a function of government intervention. What's the most effective way for a company to prevent drugs from hitting the market? Establishing a patent and limiting the supply through government intervenmtion. That's precisely what I am saying: the pharmaceutical companies have been granted too much power, but that power can only come through subsidies, tax breaks, patents, and the like via the government. You don't see Advil trying to get Tylonol taken off the shelves, do you? Why? Because they are generic ibuprofen drugs that are OTC and without a patent. They are readily available in any corner store in the US, and NOBODY complains that Tylonol or NyQuil is Price Gouging. Without the interference in the market forces that the government inherantly represents, competition drives the price down.
andres wrote:
If the government payed for everyone's bills, then the system would already be socialized and the cost of healthcare in the US would fall.
They wouldn't fall, they would be masked and distributed. Big difference.
exergenic wrote:
One of the reasons that a private health insurance market will consistently fail that has not yet been mentioned in this thread (if I have read it correctly) is the natural propensity toward information asymmetry. People generally know more about their medical history and illness trends within their family than insurers, and may choose not to disclose this information. Firms are at an immediate disadvantage, and over time must increase premiums.
That's why Underwriters generally re-assess a policy every year, taking in to consideration claim history, health, age, and several other factors. Over time, that premium should adequately reflect the risk that customer represents (actually, it might be significantly lower if the company is operating at an underwriting loss due to competition.) Risk analysis is a big part of the insurance industry, and nationalizing it essentially eliminates that sector, which I find to be more than a bit troubling.
exergenic wrote:
This is why Singapore proves to be such an interesting case study. At birth each Singaporean is issued a health account into which money is deposited each year by the government. The incentives system here is obvious, and there is some flexibility in severe cases where medical costs are necessarily exorbitant.
That's interesting, I had never heard of that.
Follow up
Gnote wrote:
And this works in many industries, but it doesn't work in insurance. The further you can spread the cost, the cheaper it will be for each person in your plan.
But without other methods to control those costs (competition, supply, etc.), the net effect would be quite slight. I'm not going to deny that ceteris paribus a larger client pool will decrease overall costs (that is after all the principle of insurance: pooled risk), but you seem to be suggesting that's the only or even the predominant factor, in determinining premium. It's not.
Quote:
Profit really isn't the issue, for the purposes of this comparison.
But it is, since competition is the primary force by which a private company is compelled to control their costs. A combination of underwriting and investment profit is how insurance companies make money. Competition in the market means that underwriting profit is as low as possible, to the point where many if not most insurance companies actually operate with an underwriting LOSS for the sake of keeping business. Without competition, there would be no reason to do that.
Quote:
The issue is really administration of the program. In a multi-payer system, you not only have multi-payers, you have multi-secretaries, multi-lawyers, multi-facilities, multi-everything
Well, lawyers aren't part of an insurance policy. Lawyers operate independently and are part of a panel counsel, with many insurance companies sharing the same law firms. Secretaries, facilities, etc is fair enough, but those are both functions of the size of the client pool as well. I dare say that any single-payer system would require at least as much manpower (and possibly as much physical space) to operate.
Quote:
In the Woolhandler & Himmelstein article I cite (available from one of the links I posted above), they discuss the cost savings that would accrue to the U.S. due to savings on administration alone.
And again appeals to the US system mean little to me, seeing that we both agree that it needs serious work.
Quote:
In a public system, there is no profit motive. Theoretically - I say theoretically because we all know that it doesn't always work this way - any profit in a publicly administered system will go back to the public. This also separates it from a private system, which requires some level of profit to be paid to investors.
I think it is far too idealistic (and that's coming from me!) to suggest that a single-payer system doesn't operate with a profit motive. They must at least cover their costs, and "profit" going back to the public occurs in both a private and public system (through vastly different means, mind you).
And this works in many industries, but it doesn't work in insurance. The further you can spread the cost, the cheaper it will be for each person in your plan.
But without other methods to control those costs (competition, supply, etc.), the net effect would be quite slight. I'm not going to deny that ceteris paribus a larger client pool will decrease overall costs (that is after all the principle of insurance: pooled risk), but you seem to be suggesting that's the only or even the predominant factor, in determinining premium. It's not.
Quote:
Profit really isn't the issue, for the purposes of this comparison.
But it is, since competition is the primary force by which a private company is compelled to control their costs. A combination of underwriting and investment profit is how insurance companies make money. Competition in the market means that underwriting profit is as low as possible, to the point where many if not most insurance companies actually operate with an underwriting LOSS for the sake of keeping business. Without competition, there would be no reason to do that.
Quote:
The issue is really administration of the program. In a multi-payer system, you not only have multi-payers, you have multi-secretaries, multi-lawyers, multi-facilities, multi-everything
Well, lawyers aren't part of an insurance policy. Lawyers operate independently and are part of a panel counsel, with many insurance companies sharing the same law firms. Secretaries, facilities, etc is fair enough, but those are both functions of the size of the client pool as well. I dare say that any single-payer system would require at least as much manpower (and possibly as much physical space) to operate.
Quote:
In the Woolhandler & Himmelstein article I cite (available from one of the links I posted above), they discuss the cost savings that would accrue to the U.S. due to savings on administration alone.
And again appeals to the US system mean little to me, seeing that we both agree that it needs serious work.
Quote:
In a public system, there is no profit motive. Theoretically - I say theoretically because we all know that it doesn't always work this way - any profit in a publicly administered system will go back to the public. This also separates it from a private system, which requires some level of profit to be paid to investors.
I think it is far too idealistic (and that's coming from me!) to suggest that a single-payer system doesn't operate with a profit motive. They must at least cover their costs, and "profit" going back to the public occurs in both a private and public system (through vastly different means, mind you).
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