Healthcare rationing: The problem with public healthcare that no one wants to discuss.

@maxdancona,

maxdancona wrote:

I don't know very much about health care in Germany. My interest is in discussing the proper way to reform the US health care system. Of course the German experience is helpful as a example of the pros and cons.

There are articles the indicate that health care rationing in an current issue in Germany. Any health care system needs to make difficult decisions around limited resources. This isn't a surpise.

Quote:
Patients are not always receiving optimal treatment because Germany's healthcare system sees its doctors stretched to their limits. There is simply not enough money in the healthcare coffers, according to the president of Berlin's Medical Association, Guenther Jonitz.

"Hospitals are understaffed and doctors are left holding sole responsibility for a patient's well-being," Jonitz said. "It is a question of political mismanagement."

According to Jonitz, the government has pulled between 10-20 billion euros per year out of general health insurance over the last 10 years.

German hospitals are stretched to the limit, say bosses

"An unlimited demand for medical care cannot be paid for and cured by limited resources," Jonitz told Deutsche Welle.

"We need to take responsibility from the shoulders of the doctors and start an open discussion about what is really necessary. One that will promote the best medical care for the patient," he said.

https://www.dw.com/en/german-doctors-fear-health-care-rationing/a-5139759

(A more scholarly look at health care rationing in Germany)

https://link.springer.com/article/10.1007/s11019-012-9423-7

The need to balance need with resources is a fact of life in any system.

I'm ignoring Izzy's silliness. Walter, I would like to hear your respose on this post.

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@maxdancona,

maxdancona wrote:

The need to balance need with resources is a fact of life in any system.

I agree with that.

There's a lot to complain about with our system - especially, by those who compare it to "the better times" decades ago. (Funerals were paid by the mandatory health insurance until about 20 years ago!)

But compared to other other countries, we're doing quite good. Even without reflecting that's a 140-year-old system.

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Currently in the US (aside from certain preventive procedures or regular checkups), your health insurance gets to decide what is covered and not covered. In some ways, I do not see too much difference between "socialized" medicine and this.... now this is not rationing, but it is more what they will cover or not cover. You can as a patient or parent of a patient try to fight it out with them, but these insurance companies hire "independent" doctors that determine if a procedure or other medical thingy is necessary. I quote independent because of course the insurance company is paying them and thus it is in the independent doctor's best interest to side with the insurance company so they can continue getting paid for their independent opinion.

I had a situation where my daughter had ACL surgery - we were fortunate to get the head of Boston Children's Sports and Medicine as her surgeon. In the recovery process there were a couple of things he insisted she get in order to recover fully, one of which would help to lessen the amount of time needed with physical therapy (in the end probably costing the insurance company less money) and the second to lessen the chance of re-injuring or causing her other ACL to tear (which is common to happen in athletes if they tear one ACL). Insurance company said no - not needed. I went back to her surgeon and told them the insurance company said neither was medically necessary and asked him if in his opinion if this was nice to have or medically necessary. His opinion was yes both are medically necessary. Went back to the insurance company - where they got an "independent" doctor's opinion which of course sided with the insurance company.

Guess what I paid out of pocket - I think our surgeon trumps some random doctor seeing his credentials are as follows: "Orthopedic Surgeon, Sports Medicine Division; Professor of Orthopedic Surgery, Part Time, Harvard Medical School
Board of Directors, US Rugby Football Foundation; Team Physician, US Figure Skating; Finish Line Director, Boston Marathon" - not to mention torn ACL is his specialty.

I feel for those people that do not have the ability to pay out of pocket. As I personally know kids who have torn both their ACLs due to not having this extend of recovery as her surgeon promoted.

Sorry for the extra venting - still irks me today -

So basically my point being is instead of the insurance companies determining what is medically necessary the government will. I, honestly, do not like either choice but I do not have all much faith in the government making good decisions. And I do feel I will have less choices if the government were to fully take over.

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@Linkat,

Doctors don’t have third parties like insurance companies saying what is and what isn’t necessary.

Also talking about healthcare systems in the middle of a pandemic is unfair. There are huge strains on health systems right now and that’s all down to Covid.

What needs to be borne in mind is cost, the NHS always performs much better under a Labour Government than a Tory one because it gets adequate funding.

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@izzythepush,

izzythepush wrote:

Doctors don’t have third parties like insurance companies saying what is and what isn’t necessary.

In a sense they do - they have state medical boards that do monitor them. The medical board is in charge of the licensing and regulation of physicians.

Insurance companies have so-called in the network vs out of the network doctors. Depending on your insurance company you can use either only in the network or either (whereas out of the network you need to pay a higher amount).

An in the network doctor is one approved by your insurance company so you would think they would "trust" the doctor has the knowledge to determine what is medically necessary. Insurance companies are not doctors - they are not medically licensed nor have the knowledge of what is best for a patient. They try to pay out as less as is at all possible so it is in their best interest to limit the amount that is medically necessary and to have independent doctors that they pay for to determine what they think is medically necessary.

And this did not happen during covid - this happens several years ago.

Here is the logic of insurance companies -- one item that the insurance company refused to pay for was to rent a CPM machine. This helps a patient after surgery to get a range of motion in their leg rather than just having it stay motionless for the couple of weeks you are not supposed to put weight on your leg. If you do not have this - then your PT sessions could end up being doubled because they will have to work on getting your range of motion before they can work on your actual return to strength. Additional PT costs would be at least another $1k whereas renting the machine would be around $150 - $300 depending on how long the doctor recommends using it.

Similar thing custom brace is about $500 - whereas tearing your acl again (which again is common if you do not properly recover the first time) will cost $25 - $50k.

And other insurances do cover this - so some have approved these as medically necessary and some do not.

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@Linkat,

I am philosophically in favor of health care rationing. You can't give every patient everything they might need (I am being careful to choose my words here). The United States provides top care to people in the middle and upper classes. Where the system falls apart in the US is for the working class and poor.

A couple of months ago I showed up to the emergency room (via ambulance) with stroke-like symptoms. Over the next three days I received $36,000 worth of medical care including a CAT scan, an MRI and two ultrasounds. Add to that an emergency room visit, a hospital stay, consults with a half dozen doctors of different specialties, nurses. blood tests etc. I did not pay a cent for this care (I may have to pay a few hundred dollars for my part of the ambulance ride).

After all of these expensive tests they found nothing (the neurologist actually said I have a "fantastic brain"... which probably caused some swelling).

My question is was a CAT scan and an MRI really necessary? These are expensive tests, and I question whether the chance that one would pick up something the other missed justified the price tag. In my defense, I chose to call the ambulance, after that the doctors made all of the decisions (I just went along).

What I know for sure is were I less wealthy with worse insurance, I would have never receieved all of this care. If I were poorly insured, I would have been given one scan at most and then sent away without much fanfare.

I suspect that in most countries... two expensive brain scans would never have been done. Americans get a lot more expensive tests and procedures than are considered rational in other countries. That drives up health care costs without the corresponding improvement in outcomes.

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@Linkat,

In the US doctors complain about being pressured to do unecessary tests. Pacients will demand expensive tests based on something they heard and read. The doctor will say no, that isn't justified by the cost and risk.

If the the million to one chance the doctors erred, he will be sued out of existance by the patient.

Doctors don't want to take the risk, and this means that unecessary (and sometimes harmful) tests are done without the rational need.

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@maxdancona,

maxdancona wrote:

I suspect that in most countries... two expensive brain scans would never have been done.

Here in Germany, it will be done in any hospital with a stroke unit.
Costs here would be 30 Euros for the hospital plus 10 Euros for the ambulance.

If you'd be driven to a hospital without such a unit, you would get the same - but done with more driving by ambulance. (Costs are the same as above for those three days.)

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@maxdancona,

I have not heard of this - maybe because I never insisted on this - I highly doubt that my insurance would cover for these tests. As a matter of fact - my daughter had to get pre-approval from the insurance company for MRI to determine if she indeed had a torn ACL. I did not delay though - I did sign saying I would pay for the MRI even if the insurance did not approve same for all else involved.

I had to go back to the insurance company to try to get them to cover for those items her surgeon insisted were medically necessary. Probably cost them more money as I made them go back several times. More the principal -- the positive even though I had to pay - she did not re-injure (fingers crossed this continues) whereas a teammate of hers did not do all these things and within a year after recovery tore her other ACL.

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@izzythepush,

izzythepush wrote:

The thing is, America won’t be starting from scratch like the Labour Government had to do.

There are UHC systems throughout the developed world, what is and what isn’t covered is on record.

The most telling fact that Max has left out is that America spends more per capita on social healthcare yet still does not have UHC.

That’s a scandal he can’t address.

No American can. There is no rational reason why we are in the state we are with regard to our healthcare.

What we should be doing is hanging our heads in shame. As was noted early on...there are third world nations handling this problem on a better plane.

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@Frank Apisa,

Frank Apisa wrote:

What we should be doing is hanging our heads in shame. As was noted early on...there are third world nations handling this problem on a better plane.

I am not here to defend the Amercian system, but ideological claims like this one are nonsense. Name a third world nation that is "handling this problem on a better plane". Give me a third world country and we will compare accessibility to healthcare, infant mortality and life expectancy.

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@maxdancona,

Cuba.

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@maxdancona,

maxdancona wrote:

Frank Apisa wrote:

What we should be doing is hanging our heads in shame. As was noted early on...there are third world nations handling this problem on a better plane.

I am not here to defend the Amercian system, but ideological claims like this one are nonsense. Name a third world nation that is "handling this problem on a better plane". Give me a third world country and we will compare accessibility to healthcare, infant mortality and life expectancy.

Cuba.

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@izzythepush,

izzythepush wrote:

Cuba.

Oops. Obviously we are thinking on the same plane here, Izzy.

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@izzythepush,

izzythepush wrote:

Cuba.

In any case, to say that "worse than a third world nation" is hyperbole...is itself an indictment of the situation in America.

We should be head and shoulders above any country on the planet with regard to handling this issue. We should be number one...since we have the most robust economy on the planet. (That will almost certainly be eclipsed by China during the next decade.)

Who give a damn if we may have to occasionally have to ration a few procedures for the nonce. We should be moving toward Universal Health Care YESTERDAY. And if we have to refine it later...so be it.

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@izzythepush,

Ok, Izzy scores a point for Cuba.

In Cuba there is absolute government control. If someone in Cuba is dying of cancer, and the government decides it isn't worh the resources to keep you alive, you die.

There is an advantage to government control, it means limited resources can be targeted to where they do the most good.

Additionally, the community based medicine model in Cuba is simply a good idea that the US should consider.

I conceed the point to Izzy. He is right. Cuba is an example of a third world country that has better outcomes than the US.

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Quote:

If someone in Cuba is dying of cancer, and the government decides it isn't worh the resources to keep you alive, you die.

And we all know who makes sure the island has as few resources available as possible.

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@maxdancona,

maxdancona wrote:

Ok, Izzy scores a point for Cuba.

In Cuba there is absolute government control. If someone in Cuba is dying of cancer, and the government decides it isn't worh the resources to keep you alive, you die.

There is an advantage to government control, it means limited resources can be targeted to where they do the most good.

Additionally, the community based medicine model in Cuba is simply a good idea that the US should consider.

I conceed the point to Izzy. He is right. Cuba is an example of a third world country that has better outcomes than the US.

There are many other third world countries that surpass America in providing some, if not all, universal healthcare.

Here is a link to a list of them:

https://en.wikipedia.org/wiki/List_of_countries_with_universal_health_care

Included are such world powers as Botswana, Ghana, Rwanda, Tunisia, Bhutan.

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@Frank Apisa,

I will give you Cuba. I wont give you Botswana (which has worse outcomes in life expectancy and infant mortality and access to health care in rural areas).

You would not be happy receiving health care in Botswana.

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@maxdancona,

That's not much different from dying because an insurance company says it isn't worth the cut in profits to keep you alive.

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Healthcare rationing: The problem with public healthcare that no one wants to discuss.

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