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It's the Prices, Stupid

There are a lot of problems with the US Healthcare system that prevent the ideal capitalist model from transferring its invisible-hand efficiencies to make us all well at minimal cost. 

The most obvious problem is people rarely price-shop prior to purchasing healthcare services. Moreover, even if they did, no one knows how much anything costs

Instead, a parasitic multilayered economy has evolved around the confusing and wasteful billing systems. Costs vary wildly based on insurance negotiations, not quality or efficacy. 

Now California wants to control prices directly - using the Medicare payment rate as a baseline. Proposed legislation would employ a nine member comission to set hospital charges and doctor fees.

It would be sort of a back door way to achieving the same effect of a single payer healthcare system, writes Vox's Sarah Kliff.

This system would be similar — but not quite the same — to something we usually call all-payer rate setting, where the government doesn’t run all the health care insurance plans but does tightly regulate the prices they charge. 
All-payer rate setting essentially shares the same goals of single-payer: It aims to increase efficiency and reduce insurer overhead in the health care system. Single-payer does this by eliminating private plans for one government plan. All-payer rate setting gets there by setting one price that every health insurer pays for any given medical procedure.
What's interesting is that this is not a new idea. Apparently Maryland has been using a sort of all-payer rate setting for years under a federal waiver. It is the only state currently doing so, but other states tried it in the 1980s.  That said, countries like Germany and Switzerland also use all payer rate setting to keep costs under control.

Why does setting one price reduce costs? Studies have found that a the same procedure may vary in cost by thousands of dollars based on the size and negotiating skill of the insurance carrier. This creates an inefficient system that requires a whole sub-economy of billing clerks and subcontractors just to figure out what to charge for each procedure.

Single-payer health care systems save money in two ways: reducing administrative costs and increasing the bargaining power of health insurers. This is true of all-payer rate setting systems, too.
Healthcare prices are rising at the fastest level in years, California's proposed legislation may be once politically feasible way to try and reign those prices in.

Required Reading:

All Rate Payer Setting: Back Door to Single Payer? 
California's Ambitious Plan to Set Healthcare Prices


Stories of Those We Carry: Green Glasses

The sun was out - rare this far north on an early spring day.

Visiting cousins from someplace else, you walked along the beach collecting shells and letting sand get between your toes.

Letting the cold water exhilarate your young skin to life.

As late afternoon passed, you and your cousins, 11 and 13, wandered down the beach away from the rented house in the dunes.

At some point the undertow saw your brown 12 year old ankles and pulled you out to sea.

Your cousins heard you struggling in the water, ran to get help, but could not find the unfamiliar house among the unfamiliar dunes.

Finally your cousin knocks on a stranger's door.

Sirens, boats and helicopters race to search the waters, but you are already on the beach.

Too cold to be dead when the paramedics find you.

We know at that when someone goes into the frigid spring surf, they are not coming here to this little hospital.

They are not coming here alive.

The radio crackled with desperation.

The little hospital emergency department is so full that I have to move a patient out of a room to prepare for your arrival.

Your departure.

Still 30 minutes up the beach, code three.

CPR in progress.

You arrive stripped naked and wrapped in blankets, yet somehow your green framed glasses are still on your face.

The paramedic bleeding salt in this dry suit.

Saltwater in his eyes.

Sand sticking to your brown skin.

Needle in the bone of your left leg.

Wires and tubes.

You are almost warm enough.

It is hard to work, silent, knowing.

I turn and find your father and cousin 13 are being brought into the room.

They sit in chairs in the corner, watching us with empty eyes.

The doctor bends on one knee in front of your father to speak to him, but your cousin must translate the words.

Your cousin had run into the water at first.

He ran heroically, up the beach.

He had screamed your name as they searched.

His voice is steady and slow as he tells your father what he already knows.

Because I have no words of comfort in any language for a father in this situation.

I close your eyes.

I bring your green glasses and hand them silently to your father.

They remind me of my daughter -- the same age -- and the glasses that she wears.

There is only one of me.

A father of a 12 year old girl.

A nurse in a rural emergency room.

I have to close the curtain on this room and its silent sobbing.

I have to meet the next ambulance as it arrives at the door.


When I read about #thosewecarry on twitter, this is the case that came to my mind. One of many, that I carry. Read more at or follow The Haunted One on twitter at @thosewecarry


The fragmented US Healthcare system wastes billions just trying to collect bills.

Because the US healthcare system is a mess, it requires armies of people just to figure out who pays what. Those hours and hours of work are a tax on the system, making every interaction more expensive, according to a study recently published in the journal of the American Medical Association.  

The unnecessarily complex, fragmented, and inefficient system of billing, coding, and claims negotiations in the US health care system employs enough people to populate small nations," the pair wrote in an editorial that accompanied the study.
There is no apparent reason for this, they argued. Outside the healthcare industry, it might take about 100 full-time workers to collect $1 billion worth of bills. But when doctors are involved, it takes "an astounding 770 full-time equivalents" to collect the same amount of money, they wrote.
"The process of moving money from payer to hospitals and physicians in the United States consumes an estimated $500 billion per year," they continued.
Read it: 


If you think we are prepared for a pandemic, think again.

We are in one of the worst flu seasons in recent decades with thousands of Americans dying every week and the Trump Administration is proposing huge cuts to health care access, spending and public health. 

Indeed, Republican efforts to cut access to healthcare -- affordable healthcare -- for every American put us on the path to a deadly global pandemic. 

AS reported by Futurism, The Director of the World Health Organization Tedros Adhanom explained: 
The threat of a global pandemic comes from our apathy, from our staunch refusal to act to save ourselves — a refusal that finds its heart in our indifference and our greed.
“Universal health coverage is the greatest threat to global health,” Tedros proclaimed. As the audience shifted in their seats uncomfortably, he noted that, despite the fact that universal health coverage is “within reach” for almost every nation in the world, 3.5 billion people still lack access to essential health services. Almost 100 million are pushed into extreme poverty because of the cost of paying for care out of their own pockets.
The result? People don’t go to the doctor. They don’t seek treatment. They get sicker. They die. And thus, as Tedros explained, “the earliest signals of an outbreak are missed.”


The Myth of Islands

An Island is a lie.

On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.
I meet a lot of people who until that moment thought that they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

I have seen doctors and law enforcement officers that I worked with take their own life.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.


This essay was originally written for the The Daily Astorian and published on 4/29/2016.


The Avalanche of Death: This is just the start of US healthcare's collapse

The tax plan passed by the GOP last night is mostly a sop to their donors with some ultra-conservative red meat thrown in to win a few senators who may have once pretended to care about fiscal responsibility.

However, one thing included in the bill is essentially a repeal of the individual mandate to have health insurance -- a key component of the Affordable Care Act.

With this mandate gone, millions are expected to lose access to health insurance, and those of us that still have health insurance can expect it to get more expensive.

The reason is simple -- and the basis for all insurance programs. If something is expensive, you spread the cost out over a large group of people so they can pay small amounts. The problem with health insurance is that not enough younger people sign up for it.

That leaves only older, sicker people paying in to the system. The individual mandate sought to increase number of people paying into insurance pools so as to spread out the costs. Moreover, younger people get sick too -- not as often perhaps -- but they get in accidents, get sick, have sick kids. There is good reason to have insurance even if you are relatively healthy, and the more people with insurance, the lower the costs for each individual.

However, drop the mandate and many of those people will likely leave the pool. That means increased insurance premiums for the people who are left.

As premiums go up, fewer people can afford to buy health insurance and more drop out.

Wash, rinse, repeat.

Meanwhile, the Trump White House and Republicans are already planning to pay for their big tax cut with "entitlement reform." That is the GOP's expression for cutting Medicare, Medicaid and Social Security.

It is something they've wanted to do for a long time. Now they've created an excuse - the tax cuts could trigger forced spending reductions in Medicare starting as early as next year. 

Cuts to those programs will lead to more uncompensated care, which will make healthcare more expensive for insurance programs, which will lead to higher premiums.

More sick people not getting the care they need.
More medical bankruptcies.
Fewer providers.


Vox: Tax Bill is Just the Start of the Obamacare Collapse.
WAPO: GOP Eyes Post Tax Cut Changes to Medicare, Social Security
LA Times: After Giving Tax Cuts to the Rich, GOP Will Cut Social Security, Medicare
Forbes: How the GOP Tax Bill Will Blow Up Medicare
NYT: The Tax Bill's Automatic Spending Cuts

Own it and Learn

As a nurse, I hate making mistakes.
I try not to make them, but they sneak up on you despite your best efforts.

Usually, they come when you feel like you're on top of things, like you have it all under control.

Let your guard down.
Fail to do the one thing you always do.
Fail to catch that vital bit of information at that crucial time.
Trust, when you know you shouldn't.

When I do make mistakes, I've learned that there is a professional -- and healthy -- way to cope.

1) Own it. (Admit it to team quickly and openly) Covering up a mistake, or spending time the the denial phase only makes things worse. Errors are compounded by obfuscation and willful ignorance. Admitting it to your team lets them know you made a mistake and gets them on board with helping you correct it. Moreover, it let's them know that you are aware of the error and not a incompetent idiot who can't be trusted.
2) Figure out how I can avoid repeating it. Every error is an opportunity. Figure out how you got fooled, or why you got complacent, and never let it happen again.

3) Share with peers - so they can learn from my mistakes. This is the other half of owning it publicly and will help when confessing your sins. "Man, I learned the hard way, I'll never get burned like that again."

Mistakes haunt me, they make for a long ride home and a hard time sleeping, especially when they have a negative outcome on the patient. Mistakes make me question my place in this profession and all the time I spend teaching others.

I played cornerback in high school football. Playing defensive back is tough because you will get burned for a big play eventually. The receiver knows the route, you don't. The quarterback knows it is a fake, you don't. You are at a disadvantage of knowledge. When you get burned, there's no time to get down on yourself. Pick your jock up off the turf and get back to the line, the next down is coming fast.

I learned to yearn for the next down after getting beaten by a big play. Getting it right was the only way to get the taste of getting it wrong out of my mouth.

Experience builds confidence if you learn along the way. Each experience is a piece of armor as we go into battle against the unknown. You get tougher. You get smarter, faster - you catch some little thing that you overlooked before.

The most important play is the next one - because that's an opportunity to get it right.

We can't be perfect.

But we can get better.


It's the Prices, Stupid

There are a lot of problems with the US Healthcare system that prevent the ideal capitalist model from transferring its invisible-hand effi...