Comments on: First-Dollar Coverage http://healthblog.ncpa.org/first-dollar-coverage/ Health Care Policy and Reform Insights | NCPA Wed, 23 May 2012 13:59:13 +0000 hourly 1 http://wordpress.org/?v=3.3.2 By: Devon Herrick http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70797 Devon Herrick Tue, 27 Jul 2010 21:19:04 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70797 Steve, I definitely agree doctors should be allowed (i.e. encouraged) to look for patient-pleasing services for which patients are willing to pay a premium. This might include phone calls, remote monitoring, email consults, etc. If health care is to be competitive it has to be a two-way street. I've heard many discussions -- albeit anecdotal -- of physicians that help cash-paying patients receive efficient care, yet had no incentive to act the same for insured patients. Steve, I definitely agree doctors should be allowed (i.e. encouraged) to look for patient-pleasing services for which patients are willing to pay a premium. This might include phone calls, remote monitoring, email consults, etc. If health care is to be competitive it has to be a two-way street. I’ve heard many discussions — albeit anecdotal — of physicians that help cash-paying patients receive efficient care, yet had no incentive to act the same for insured patients.

]]> By: steve http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70789 steve Tue, 27 Jul 2010 20:45:17 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70789 Oops, thx for the SDC piece. By OECD standards, we underspend on long term care. Overall spending in this area is not our major spending source. Having read on this particular area before, I would prefer the no strings attached approach used by the Europeans. Still not sure how this translates to more acute care. Steve Oops, thx for the SDC piece. By OECD standards, we underspend on long term care. Overall spending in this area is not our major spending source. Having read on this particular area before, I would prefer the no strings attached approach used by the Europeans. Still not sure how this translates to more acute care.

Steve

]]> By: steve http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70784 steve Tue, 27 Jul 2010 20:23:19 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70784 Devon- Maybe it could. I would say that in over 37 years, I have had maybe 3 or 4 patients ask what something would cost. You are proposing a major cultural change. Query- If we want docs to be more competitive, is it ok if I charge more when I am able to do so? Are we only going to allow negotiations in one direction? How would you accomplish this? Steve Devon- Maybe it could. I would say that in over 37 years, I have had maybe 3 or 4 patients ask what something would cost. You are proposing a major cultural change.

Query- If we want docs to be more competitive, is it ok if I charge more when I am able to do so? Are we only going to allow negotiations in one direction? How would you accomplish this?

Steve

]]> By: Devon Herrick http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70774 Devon Herrick Tue, 27 Jul 2010 19:29:07 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70774 Steve, Here is a blog post that discusses the trend of allowing patients to control more of their dollars like is the case with Cash & Counseling. http://www.john-goodman-blog.com/patients-managing-their-own-health-care-budgets/ Despite the problem of asymmetric information that artk speaks of, I believe patients controlling some of their own medical dollars provides them with an incentive to ask pesky question (like "how much does this cost?" or "do I really need this?"). It also goes a long way towards inducing providers to act more competitive (or at least act more attentive). Steve,
Here is a blog post that discusses the trend of allowing patients to control more of their dollars like is the case with Cash & Counseling.
http://www.john-goodman-blog.com/patients-managing-their-own-health-care-budgets/

Despite the problem of asymmetric information that artk speaks of, I believe patients controlling some of their own medical dollars provides them with an incentive to ask pesky question (like “how much does this cost?” or “do I really need this?”). It also goes a long way towards inducing providers to act more competitive (or at least act more attentive).

]]> By: Bart Ingles http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70772 Bart Ingles Tue, 27 Jul 2010 19:22:48 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70772 Point taken about copays. I really meant any point-of-sale liability, including deductibles and coinsurance. Coinsurance-- an amount proportional to actual cost-- would be an improvement over flat-rate copayments. Whether paying full price using an HSA is be more effective than, say, 20% coinsurance would depend on whether the HSA is regarded as the same as cash, or merely as "Monopoly money" with discounted value. Also, I didn't mean to suggest that insurance terms should be tailored to individual income levels; rather that any external subsidies should be applied so as to have this effect. Point taken about copays. I really meant any point-of-sale liability, including deductibles and coinsurance. Coinsurance– an amount proportional to actual cost– would be an improvement over flat-rate copayments.

Whether paying full price using an HSA is be more effective than, say, 20% coinsurance would depend on whether the HSA is regarded as the same as cash, or merely as “Monopoly money” with discounted value.

Also, I didn’t mean to suggest that insurance terms should be tailored to individual income levels; rather that any external subsidies should be applied so as to have this effect.

]]> By: steve http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70763 steve Tue, 27 Jul 2010 19:00:03 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70763 Private insurance costs have gone up just as fast. "We do this in the Cash and Counseling program for the Medicaid disabled and it works like a charm." Have you published this somewhere? Steve Private insurance costs have gone up just as fast.

“We do this in the Cash and Counseling program for the Medicaid disabled and it works like a charm.”

Have you published this somewhere?

Steve

]]> By: John Goodman http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70761 John Goodman Tue, 27 Jul 2010 18:33:09 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70761 I actually don't believe in copays -- especially copays adjusted for income. I believe in paying market prices, which are determined by providers competing for patients based on price and quality. It's just as easy to establish a Health Savings Account for poor poeple as it is to give them a Blue Cross card. (Well, maybe not as easy, but certainly worth doing.) We do this in the Cash and Counseling program for the Medicaid disabled and it works like a charm. I actually don’t believe in copays — especially copays adjusted for income. I believe in paying market prices, which are determined by providers competing for patients based on price and quality. It’s just as easy to establish a Health Savings Account for poor poeple as it is to give them a Blue Cross card. (Well, maybe not as easy, but certainly worth doing.)

We do this in the Cash and Counseling program for the Medicaid disabled and it works like a charm.

]]> By: Bart Ingles http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70758 Bart Ingles Tue, 27 Jul 2010 18:08:41 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70758 Artk seems to base his argument on two questionable beliefs: (1) that no level of cost sharing is appropriate, and that any resulting cost savings can only come at the expense of having worse outcomes; and (2) that the people he's debating are assumed to believe cost sharing is everything and should be imposed without regard to ability to pay. Perhaps there are people who believe (2), but it's not very evident here. But it seems clear to me from personal experience that awareness of cost can reduce waste. It's caused me to raise questions with my physician that resulted in prescription changes. And doctors will try to save a patient money if they know that patient is going to be impacted. But cost-sharing does need to be at a level appropriate to the patient's financial situation. A $5 co-pay may cause a poor person to forgo needed treatment, while being too small an incentive for wealthier patients. Also, I have a problem with John Goodman's equating "free at point of sale" with "free". It seems to me that charging high premiums for supplemental coverage with zero co-pays is actually worse than free: individuals may actually try to over-consume in order to recoup the overly-high premium. Co-pays need to be in balance with premiums; to incent savings, you need to increase co-pays and reduce premiums. Artk seems to base his argument on two questionable beliefs: (1) that no level of cost sharing is appropriate, and that any resulting cost savings can only come at the expense of having worse outcomes; and (2) that the people he’s debating are assumed to believe cost sharing is everything and should be imposed without regard to ability to pay.

Perhaps there are people who believe (2), but it’s not very evident here. But it seems clear to me from personal experience that awareness of cost can reduce waste. It’s caused me to raise questions with my physician that resulted in prescription changes. And doctors will try to save a patient money if they know that patient is going to be impacted.

But cost-sharing does need to be at a level appropriate to the patient’s financial situation. A $5 co-pay may cause a poor person to forgo needed treatment, while being too small an incentive for wealthier patients.

Also, I have a problem with John Goodman’s equating “free at point of sale” with “free”. It seems to me that charging high premiums for supplemental coverage with zero co-pays is actually worse than free: individuals may actually try to over-consume in order to recoup the overly-high premium. Co-pays need to be in balance with premiums; to incent savings, you need to increase co-pays and reduce premiums.

]]> By: Bruce http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70754 Bruce Tue, 27 Jul 2010 17:40:31 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70754 If "real consumer choice" means that patients must be doctors, then I suppose there isn't real consumer choice in any market -- because there is always asymmetry of information. Even so, we seem to do quite well in the market for cameras, automobiles, cell phones, personal computers, etc., where the asymmetries are at least as large as they are in medicine. These markets are not perfect. But they serve consumer needs a lot better than if we had a Blue Cross-type entity making decisions for us. If “real consumer choice” means that patients must be doctors, then I suppose there isn’t real consumer choice in any market — because there is always asymmetry of information. Even so, we seem to do quite well in the market for cameras, automobiles, cell phones, personal computers, etc., where the asymmetries are at least as large as they are in medicine.

These markets are not perfect. But they serve consumer needs a lot better than if we had a Blue Cross-type entity making decisions for us.

]]> By: artk http://healthblog.ncpa.org/first-dollar-coverage/comment-page-1/#comment-70749 artk Tue, 27 Jul 2010 17:08:23 +0000 http://www.john-goodman-blog.com/?p=11962#comment-70749 Details count, you need to reread the Rand study. First, they found that among poor populations, cost sharing caused worse outcomes. Then again, since the reimbursement schedule for Medicaid providers are so inadequate, that's our way of saying we don't think the poor are entitled to good health care. Second, cost sharing didn't change quality of care or appropriateness of treatments. That goes to my point about information asymmetry, real consumer choice in health care can only exist if we're all doctors, and that's not going to happen. Details count, you need to reread the Rand study. First, they found that among poor populations, cost sharing caused worse outcomes. Then again, since the reimbursement schedule for Medicaid providers are so inadequate, that’s our way of saying we don’t think the poor are entitled to good health care. Second, cost sharing didn’t change quality of care or appropriateness of treatments. That goes to my point about information asymmetry, real consumer choice in health care can only exist if we’re all doctors, and that’s not going to happen.

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