Dr. J. has written at great length regarding his opinion on Obamacare and the creeping control government has had on the health-care system through payment (medicare/medicaid), legislation and regulation.

What he didn’t give is a patient’s perspective.

One Cziltang does so at his blog Ratland, in a thoughtful response to Dr. J.’s recent polemic, “The Problem with Third Party Payors.”

If I were designing a plan with incentives I would respond to, I would want a plan that completely covered an annual check-up (and maybe one more visit to the doctor per year). Pretty much everything else that’s routine (office visits, prescriptions) I would want to be on a percentage basis after a deductible rather than having fixed co-pay amounts (under my old insurance, the office visit co-pay was the same, no matter what else was done, the “what else,” of course being billed later). To encourage their use, fully covering the $4 generics might be a nice touch. I would still want catastrophic events that require hospitalization to be covered. 

On the other end of the spectrum, I’d like to find a doctor that would offer a discount if I handled submitting the claim to the insurance company and just paid the bill myself. In a set-up like that, I’d also like to find a doctor who offered a discount for payment in full at the time of the visit. Surely not having staff tied up in claims processing and getting paid up front would be worth something to a practice. Of course, having a list of visit and procedure costs would be nice. (Do you know what a “regular” office visit with your doctor costs? Mine is about $80. The Pain Management specialist was $120 just to walk in the door, have a nurse do a med check, and get the handwritten prescriptions for the coming month¹ – no doctor involved, except to sign off on the prescriptions.) 

I have no idea whether any of that would be economically viable for an insurance carrier. I just know those are the kinds of things I would respond to. But, in lieu of Obamacare, and absent a lot of the current restrictions, I’m pretty sure someone would offer some choices that would reward customers who actively tried to minimize costs. And, I believe it’s time we tried something, anything, that would reward personal responsibility.

His whole essay is worth reading.

Ultimately, there are people out there with medical needs, none of us deny that. As a doctor, that’s all Dr. J. cares about, taking care of his sick patients to the best of his ability.

What is at issue is that we’ve progressively moved our system in a way that cuts the patient out of the payment process as much as possible.

Private practice groups are no longer economically viable, so practices are being bought by hospital networks. It is far easier, at present, for the hospital to manage all claims rather than let, say 10% file their own. The reason is that they are effectively generating a different bill for every insurer based on a pre-negotiated fee. For example an cardiac catheterization and stent placement may be listed as $10,000 for self pay, but Medicare/Medicaid may pay $6000 and Aetna may pay $8000, and BC&BS may pay $8500. It is far easier for the hospital based medical group to swipe a credit card for a co-pay and let the billers in an office building off campus handle the rest.

To Cziltang’s other point, his wife’s pain-management issues. This is one of the hardest fields we have in medicine. Prescription drug abuse is rampant. As a consequence doctors, out of fear of harming patients, harming the community and being criminally and civilly liable for the consequences of narcotics they prescribe are very cautious as to how they do it. Furthermore, there are state and federal laws regulate the prescribing of these drugs. Fortunately, or unfortunately, narcotics cannot be refilled. Many primary care physicians do not even bother prescribing them for anything beyond an acute pain episode, and leave chronic pain to pain specialists.

In an ideal world, he wouldn’t have to go through the added expense of going to a pain specialist monthly for a prescription.

The current system, and any system designed to repair and/or replace what we currently have will have its weak spots and blind spots. It is unfortunate, but it is the reality of life.

Fortunately people like Cziltang gets it, and Dr. J. wishes more did. He wishes the very best to Cziltang, the Head Rat, and all their Ratlings.

Dr. J.