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Category: Healthcare

Going Off the Rails With No Way Back

Going Off the Rails With No Way Back

At the risk of sounding like a curmudgeon once again, there are some things that need to be said. If I’m a curmudgeon — I don’t think I am — so be it.

What brought this sudden bout of curmudeonness on, you ask? It began Saturday morning with telephone conversations with two different bankers in Maryland. I’d written two checks to a friend of mine visiting from Albania, repayment of an old debt. She took the checks to a local branch of Wells Fargo Bank (I’m naming names this time), the bank on which the checks were drawn, and someone from the branch called me to verify the checks’ legitimacy. Okay, I can see the point of that, though I wonder if they would have done the same if my friend was American or had, say, a British or Canadian passport and not an Albanian one. I also have questions about the need for a call given that Wells Fargo seems to have policies in place that deliberately make it as difficult as possible for customers to access their own funds. But that is a whole other story.

In any case, one of the checks was for $2,000.00, and the other one was for $9,000.06. I put the numerical amount as I always do, $2,000.00/100 for the first check, and $9,000.06/100 for the second one. And then I wrote out the amount in the proper format, the one I’ve been using for some 50 years virtually without incident: Two Thousand and No Hundreths Dollars, and Nine Thousand and Six Hundreths Dollars. Okay, granted, the proper spelling is hundredths, but close enough for government work since the words spell out what the numerals already show, and in my haste I dropped the “d.” But that wasn’t the issue.

Now, I don’t know, but I think anyone from about the age of 5 should know that a hundredth of a dollar is a cent. A penny. One hundredth of a dollar is one cent, six hundredths of a dollar is six cents. Even misspelled, I’d bet most 5 year olds can figure that out. But apparently this fine point is lost on Wells Fargo bankers, and I had to explain to two different genius bankers that Nine Thousand and Six Hundreths (sic) Dollars was not $9,600, but $9,000.06. The first banker said their branch policy was not to accept checks with the cents expressed that way. That made no sense to me, but finally he conceded and said they’d cash the checks. All good, right?

Not quite. A few minutes later another banker, the first one’s manager, called me, and after a few unnecessary and unwanted pleasantries, she repeated that the branch didn’t normally accept checks where the cents were expressed as they were on my check. She had me read off the amount of the check, and confirm the intended amount. I was rapidly losing my patience with this whole thing, and I told her I’d been writing checks like this for 50 years, it was the proper way to write a check, and what exactly didn’t she understand? She then feigned a brief reconsideration of the matter, and finally confirmed that they would accept the check. Hurrah. I got to tell a banker what should have been obvious to her by reading the check as it had been written. Duh.

Now I have better ways of spending my Saturday mornings than explaining the obvious to bankers, but this whole affair served to remind me the extent to which this country is going to hell in a hand basket. The signs are increasingly everywhere, how far off the rails we’re going, this just being the most recent one. It seems people, and the country as a whole, just get stupider and stupider by the day.

I’ve railed against the madness in the direction we’re headed before, but it’s time to do it again, drilling down a bit this time.

In the course of a typical day, I get messages – obviously written on a phone with a run-away spell corrector – that are virtually incomprehensible. I’m asked questions that I already answered, sometimes multiple times. And I get abbreviated messages that fail to respond to issues I raised. In short, I can almost always tell when someone is writing me from a phone, and the communication is seriously impaired as a result. This is a significant matter, since communication should be primary, not to mention I don’t understand how people don’t go crazy typing and reading on a small screen. Well, maybe they do, and we just don’t have a name yet for this mental illness.

If you’re a parent in this country, it probably doesn’t come as a surprise to you that your little darlings are no longer expected to learn cursive writing. At one point, some 45 states and the District of Columbia had dropped the requirement to teach cursive writing, and the dreaded Common Core was at least in large part responsible for that since Common Core doesn’t require cursive as part of the curriculum. Now blaming Common Cause for stupidity is a bit like blaming phones for errors. It’s the people behind Common Core who are exhibiting their ignorance, and the curriculum is just the symptomatic outcome of that.

There has been some retrenchment in a handful of states that realized the folly of dropping cursive writing from the curriculum, but overall this country is on the verge of entering a new Dark Ages where kids can’t even sign their own names. The idea is that they can do everything on a keyboard, but somehow that seems equivalent to saying they don’t need to learn to walk since they can get driven around everywhere by their parents.

Additionally, as studies confirm, the ability to write, and not just type, promotes some cognitive and motor skills that typing does not. Writing is not the same as typing, and while both skills might be worthwhile, school districts and states don’t want to spend the money teaching both. So out goes cursive writing, and with it one of the traits of an educated person. And people wonder why I’d never put any child of mine in a public, and probably most private, schools.

While this has been going on in more recent years, another long term trend – grade inflation in the nation’s colleges and universities – has been underway for more than half a century. It’s true that a degree of grade inflation began during the Vietnam War years, Recent GPA Trendswhen I was in college. Some attribute this to the desire on the part of many professors to keep students out of the draft, which worked for awhile, but based on my own experience it also probably had to do with the proliferation of pass-fail grading during the turmoil of years of sit-ins, walk-outs, and student strikes that closed some institutions, including the one I attended, for nearly entire semesters. But the grade inflation of that period pales to what has been going on since the 1980s, when grade-point averages have been rising an average of 0.1 points a decade, and the percentage of A grades given has gone up 5 to 6 percentage points a decade.

Since the 1990s, the A grade is the most common grade given in four-year colleges, and As are now three times more common than they were in 1960. At that time Cs were most common, and in my own era, Bs were most common. Now if they don’t get an A, students are at the professor’s throat as if the failing rests with the prof and not with their own performance. If you believe that is because college students have gotten that much smarter since 1960, I have a nice athletic building on a fine campus I’d like to sell you. Very good price. Just sign right here. Oh, wait, you can’t sign, because you never learned cursive. Okay, put your “X” on the line there.

Having been a college professor, I can tell you there is a strong tendency toward treating what are supposed to be young (and sometimes not so young) adults as 50 Years Rise of A Gradechildren. There is a stress on not offending the students, sandwiching any critical remarks in between praise, not being unduly harsh in comments even in the face of abject and repeated refusal on the part of the student to follow guidance. This is called the Student as Consumer Era, and it is indicative of schools that need to cultivate their students to stay enrolled and to pay the exorbitant tuitions and fees charged them and their parents. And instead of challenging their minds and belief systems, these educational institutions allow students to retreat to so-called “safe spaces” and to drive speakers with views divergent from their own off campus, allowing a new form of Fascism and sheltered closed-mindedness to run rampant on college campuses.

Moving from the swamp of so-called education, we have cars that stop themselves or keep themselves in their own lanes, ostensibly so their owners (“drivers” is too strong a word for them) can text and talk on the phone. Things seem increasingly geared toward the lazy and the ignorant. My own car turns its own lights on and off, doesn’t have a key, and tells me how many miles I can go before I run out of fuel. Thank goodness it doesn’t stop itself or do that lane thing, which would be way beyond what I would tolerate of my car. It does open its own trunk, though, for unknown reasons and at very inconvenient times, sometimes multiple times in a row. I guess taunting its owner is part of the deal. I can almost hear it laugh when it does this.

In the course of all these trends, we continue to lose human contact at an almost alarming rate. My most recent two forays into paying entry fees – one at a movie theater, the other at a major conference I attended – were done at terminals. Gone were the friendly ticket girl and the helpful conference gatekeeper, replaced by screens and credit card readers and keyboards. That may all be more efficient, but it’s a bit disconcerting, too. My local Walmart has installed all sorts of self-check-out equipment, but I have never found self-check-out to be faster or more efficient than dealing with a human cashier, and it’s also a tad insulting, I think. If the store wants my money, it should at least have a sufficient number of humans on hand to take it. So, unless I have just one or two items and am in a major hurry, I won’t use the self-check-out.

Meanwhile, the medical profession – one area that might benefit from more, rather than less, technology in enabling improved communication between physicians and patients – remains mired back a century or two. If anyone is able to email their doctor, or even their doctor’s office, I’d love to hear about it. And our prescription drug system seems designed to breed frustration and inefficiency, and we wonder why healthcare costs continue to escalate. I’ve written on these things before, and on the inherent inequities and inefficiencies of the medical system, and the most I’ve gotten in response from doctors is a smile and a laugh, as if I were proposing absurdities.

Call me a curmudgeon if you like, but somehow this all feels like we’re headed off the rails with no way back. Maybe, as the illustration says, you’ll get it eventually, but by then it might be — probably will be — too late. I could be wrong, but I don’t think I am. Am I only the only one who feels this way? I’d love to hear your thoughts on all this, regardless which side of things you come down on.

Charts from http://www.gradeinflation.com 

The View From the Shoulder

The View From the Shoulder

To point out the obvious, I survived the surgery that was the subject of my last posting, and have been in a process of slow recovery over the past three and a half weeks. The surgery – a quintuple cardiac bypass, which I didn’t even know was a thing – went well, and I’m told my recovery has been as good as could be expected. I’m grateful to my surgeon and all the others who were involved in getting me through this, as insane as it all seems to me.

Where I’m at now is a world of difference from where I was in the first few days after the surgery. There are still lots of inconveniences and things that are not yet back to normal, but at least I’m past the excruciating pain and weakness that characterized those initial days. At that time I had to wonder why I ever put myself through such mutilation and torture, and still I can’t imagine ever going through anything like that again. I had a pretty clear sense throughout the whole ordeal that I could return to normal functioning and an active life, but I realized that if all I had to look forward to was permanent disability and struggle, as others I saw around me, I’d have a pretty hard time justifying it. Even today, as far as I’ve come, I had to wonder how the mechanisms that are my heart and body could sustain all this and keep on functioning. This is a mystery I may never unravel.

In case you’re wondering about the title for this posting, as much as I’m now ambulatory and functioning at a relative level of normalcy, I still feel I’m sitting on the shoulder of the road. Other than emails and shopping lists and questions for my doctors and a couple of business-related items, this is the first piece of any sort of coherency and even marginal creativity I’ve been able to write in 26 days. And it’s admittedly pretty thin. I’m hoping in the next several days I’ll be able to write more, and then more, and I can resume more regular posting to these blogs, but I’ve found that gathering mental energy is virtually as hard as gathering physical energy. And having anything worth saying is yet a step beyond that.

Four days past the surgery I attempted to get online, and was met with the shocking reality that I had forgotten all my passwords. I still couldn’t muster the strength to have someone fetch my laptop from its bag or to hold it on me, and trying to do things on my phone reinforced the feeling of insanity of doing anything serious on a phone, even when in normal health. I had that sense before the surgery, and that disconcerting experience only confirmed it. Two days later, when I finally did get onto my laptop, I was astounded at the number of typing mistakes I made. It was like my fingers were not in direct contact with my brain and they took on twitches and strokes that defied my best attempts to control them. Not quite as disjointed as the time I tried to work on a Turkish keyboard, but close. I’m told that anesthesia can really scramble both brain and body cells, and so I’m chalking these aberrations up to that. I’m doing a lot better now with typing and other fine motor skills, and the files on my laptop helped me recover my passwords, but the process has been a continuum.

Other bodily functions – notably an astoundingly annoying throat irritation and coughing, and problems with peeing – have slowly been recovering, and while not back to what I’d characterize as normal, are hugely better than they were in the early days.

I had five and part of a sixth day in the hospital following the surgery, and then four and part of a fifth day in a rehab center, located on the same complex as the hospital, after that. At that point I got the boot, and two wonderful friends and fellow boat people came to fetch me, assist with getting food and medications, and establish me back aboard my boat, which is my home. I don’t know what I would have done without them, and I’ll be forever grateful to them. It’s two weeks today that I’ve been back aboard, and I think returning here was the best alternative. This past Tuesday my surgeon, with some persuasion, gave me back my driving privileges, and that made a huge difference in my life. And two days ago my primary physician told me I’m very impatient. I told her I know I’m a pain in the ass, but I wasn’t challenging her expertise. That’s just me. And she laughed.

I’m going to have lots more to say about the medical and healthcare situation in this country in coming weeks and months here on FJY.US and I may have some fictional things to say about it on Stoned Cherry. I’m fortunate in that I have access to Medicare and private insurance, and that made a huge difference. It shocks some people, but I really have nothing negative to say about my insurance company. And I have lots of praise for the doctors, nurses, aides (known, it appears, as Patient Care Technicians in some circles these days), therapists, and all the others who assisted and supported me through all this. That said, when there were rare failures they were pretty notable, and one thing I came to discover is that it usually is the little things, the small details, that can have the biggest impact on a patient and the patient’s experience. I’ll have more to say on this, too.

I really feel bad for writing all this self-centered drivel, but I felt some explanation of where I’ve been for the past weeks was in order, a kind of transition from the breakdown on the shoulder I went through to getting back into the traffic pattern. I’ve seen the moon and the sun since my last posting, and so day-by-day it’s time to get on with life. I promise, barring any unforeseen circumstances, this will be the last posting focusing on this whole thing, and I now can say, enough of these adventures.

I’ll be pulling off the shoulder pretty soon, so watch this space for what’s to come.

Physician, Heal Thyself!

Physician, Heal Thyself!

No, this isn’t about drugs or addiction or ODing, or any of those things. It is about frustration, though. Frustration with the medical profession. Frustration in trying to create sense where sense seems not to exist. Frustration that can lead to scenes such as in the image. Fall down on the floor, tear out your hair, rend your garments sort of frustration.

To be perfectly clear, this posting is based on a personal incident – drama is more like it – playing out now with certain elements of the medical profession. To protect both the innocent and the guilty, I’m not going to name any names. Now. But if I continue to be stymied, that decision might change. Watch this space.

If you’ve read my piece on The Biggest Shell Game in the World, which you should before reading on here, you know how I feel about the so-called “healthcare system” we have in this country. You’ll also see I elaborated on some specific actions that might help ease the growth in the cost of healthcare. That posting focuses on the macro dynamic of the system. This posting focuses on the micro dynamic, the one on the doctor level.

It’s no longer a laughing matter – it never was a joke – to say that much of the medical profession is still anchored, not just in the last century, but maybe even the one before it.

When I lived in Montana some dozen years ago, my physician – an author of the reputed Helena Heart Study, so no slouch – presented himself as advanced because he took his notes on a laptop. Why that should have been considered advanced when small computers had been in fairly wide business use for a quarter century already is a good question to ask, if you’re inclined to ask questions. Now, all the doctors I go to use laptops for their notetaking and recordkeeping. Of course, it is, at last count, 2017.

The one thing my Montana doctor did that really stood out was to communicate by email. Quick, easy, asynchronous. Email. One would think this also would be pretty standard now. That’s what I thought. I mean, I run a global business and communicate with clients all over the world at close to 100% by email. So picture my surprise to be out of Montana and in a southeastern state that also shall remain nameless (besides, I often reverse the “d” and the “i” in the name, which is embarrassing) and to find that email does not play a role in typical doctor-patient communication.

Does one even have to wonder why calling a doctor’s office often leads to more frustration, lengthy stays on hold listening to dreadful “hold” music and self-serving promotions, being asked, finally when you get past the official hold, “Can you hold, please?” (Okay, at that I’m tempted to fire back, what are my options here?)

Again, how can almost any organization in 2017 function without email? It’s not only a fast and easy means of communication, but it also can be used as a system of sending health information to patients and even, if one is allowed a bit of crassness, as a marketing device. But, no, this seems to be beyond the understanding of most doctors.

Then there are those doctors’ portals. Potentially great idea, completely mutilated, misused, and just plain not used, in execution and practice. First, they’re all clunky in that clunky way that special-purpose software (like used in lawyer and, yes, doctor offices) always is. I don’t know, maybe it’s me, but I’ve had a litany of problems with the portals of several doctors and healthcare groups. Sometimes I’d have to enter a new password each time I signed in. Sometimes things I’d want to see, like reports, are there. Sometimes not. One portal doesn’t even tell me my next appointment, which would seem pretty basic. I’ve yet to be able to get a prescription refill put through based on a request posted on a portal site. And, perhaps the biggest issue I’ve encountered, often doctors’ front offices don’t mind the sites, so sending a message to the office through the portal is like throwing a quarter down a deep well. “Pathetic” is too kind a word.

Okay, despite all that, that’s not my biggest problem nor the most immediate. Oh, no. I have a far bigger gripe, which we’ll get to now. The one that concerns the Health Insurance Portabliity and Accountabillity Act – HIPAA – and how doctors not only seem not to know much about its requirements but, worse, seem to think it exists to protect them and not the patient. Which is wrong.

I had one doctor earnestly tell me that there is a $50,000 fine attached to a single HIPAA violation. Well, he was part right. Fines can range from $100 to $50,000, or $1.5 million maximum per year for ongoing violations. What puzzled me then, and which irks me now, is that the implication was that the doctor had to protect himself against violations and resultant hefty fines. The point that was completely missed, even inverted, is that denying a patient access to his or her records in whatever way the patient deems suitable seems like a more sure route to a violation than just providing what it is the patient requests, in the form or via the means requested by the patient.

Now that doctor’s office will fax me things like test results. Some will even (horror!) email them. And then there are others, like another one of my doctors, who refuses to provide records or results in any form other than by mail, or picking it up in person. Never mind the inconvenience of the latter choice, I would defy anyone to show me how snail mail is any less prone to pilferage or misdelivery than a fax or email. I even maintain an encrypted email account for highly sensitive information. But all that is irrelevant. The Department of Health and Human Services (HHS), which oversees application of HIPAA, is clear on the subject: A provider should email, fax, or accommodate alternative delivery means as requested by the patient. Look it up. It’s right there, explicitly spelled out by HHS, in the department’s HIPAA FAQs.

That’s really the key issue: Patients have a right to see and receive their own records and results, and HIPAA exists to protect them, not the doctor or other provider. So if a patient wants his or her bloody records emailed or faxed to them, HHS says the provider should accommodate that request. But you’d never know that from the patchwork of restrictions, most of which make little to no sense anyway, that one encounters when requesting one’s records.

Of course, all this assumes that a patient has signed a statement authorizing release of information to the patient and whatever third-party designees, if any, that the patient might include in the release. Now here is a suggestion – a strong one: Why not include a check-off box with a line where the patient authorizes positively (by checking the box) transmittal of records via email or fax? Easy-peasy, and takes care of any misunderstanding. And while you’re at it, how about another line with a check-off box authorizing the same thing for any third-party designees? Two lines, and you can sleep better at night knowing the patient has asked for this and HHS says you should give it to them. And it’s in writing, no less.

All this leads to the source of my current distemperous mood toward doctors and things medical. It’s been four weeks – not hours, not days, not business days, but weeks – that I have been requesting the results of an MRI from a certain specialist. I requested that the doctor or his nurse-practitioner call me before I left on an extended trip so I could at least have a sense of what the MRI revealed. I was told, well, he probably won’t call you. He likes to do things in person.

Well, I like to do things in person, too, when that works. But in this case, it wasn’t even possible to get an appointment in less than a month or more. And I was clear that I was leaving the state and needed the information before I went.

Ha. Fat chance. Four weeks have gone by, I’ve lost count of the number of times I’ve called this doctor’s office, had my primary care physician’s office call him, even the insurance company called the office when I filed a grievance with them over this. And still I can’t get either the doctor or the nurse-practitioner (which would be fine) to speak with me and discuss the test results, much less actually get those results. Now if ever there is a HIPAA violation, it would seem this is it. It will take a formal complaint to HHS, but that is imminent. I now even have my attorney on the case.

The doctor might have his procedures, but there are two parties to the transaction, the other being the patient, and in this case this patient has different procedures. And HIPAA is on his side.

It’s bad enough having to deal with doctors and tests and health issues without having to be put under further stress and duress by providers and offices that just throw more roadblocks and obstacles in the patient’s path.

All this seems very 19th Century to me. Doctors hold themselves up as miniature deities and patients are just supposed to accept whatever inconveniences, incompetence, or affronts that the doctor and doctor’s minions subject them to. And there are others besides those discussed here. Let’s just save my rant on the prescription system for some other time, ‘kay?

If you’ve encountered any of these issues in dealing with doctors, I invite you to tell everyone about it in the comments. And if you have a different and more positive story to tell, by all means post that, too, in the comments. And if you question the premises on which this piece is based, well, fire away with that, too.

Meanwhile, I’m going to fax this piece off to a few doctors I know (I have to fax them since I don’t have their email addresses) and maybe shake a few trees. Or else things will just go on as they always do. And watch this space if I decide it’s necessary to start naming names.

Physician, heal thyself!

The Biggest Shell Game in the World

The Biggest Shell Game in the World

Healthcare has been all in the news these days with the U.S. Senate considering its version of whatever is to replace Obamacare. So it seems fitting to take a look at the intractable morass that is the American healthcare system. Which, as I see it, is better seen as the biggest shell game in the world, and as long as it is, resolving the issues surrounding it are likely to remain intractable.

You probably know what a shell game is. That’s the scam that sometimes crops up on city streets where the scammer, also known as a tosser, places a small ball or pea under one of three shells or cups, and then moves the shells or cups around on the table. The marks – people betting they can beat the tosser – have to guess which shell or cup contains the ball or pea. But of course the game is rigged, often with the ball or pea surreptitiously removed from the table altogether, so the marks lose their money. And that, of course, is the scammer’s objective. They’re not in the game for their health.

Now I don’t claim to be an expert on our healthcare system, but I’ve engaged with it enough and watched some of its inner machinations over the years to see how it resembles a classic shell game. You’ve probably seen it, too. How about those band aids that show up on the hospital bill for $8 (or whatever the current going rate is – a hospital in New Jersey charged a patient $8,200 for a band aid on a cut finger, plus $800 for a tetanus shot and a few other basic things). Or those $15 Tylenols, which can add into the hundreds of dollars during a typical hospital stay? And what about those nameless “specialists” who rush up to patients as they’re heading into the operating room so they touch the patient’s arm, crack a joke or two, and then send a sizable bill for hundreds or thousands of dollars for their “services.” And then there are those “itemized” hospital bills that can run pages long. Ever try checking one of those for “errors”?

I’ve done some research, too. For instance, the average cost of an MRI in the U.S. is $2,611. But price around to various hospitals and health centers, and you’ll find costs ranging from about $1,000 up to twice the national average (that’s what I found). Doing some number crunching, I determined the actual cost, depending on the rate of utilization and maintenance costs for any given installation, should be in the $250 – $500 range, which is close to what an MRI costs in Canada when paid for privately or with private insurance. The national average cost of a CT scan is $1,200, but the actual cost can range from $250 to $4,600. And during the discussion going on in the past week, I heard one person say they actually paid $9,000 for a CT scan. And that was after pricing around and driving something like 60 or 80 miles to get to it. What a deal!

The shell game doesn’t end there. A three-day hospital stay costs, on average, $30,000, and the average emergency-room visit runs $1,233. But I personally know of a case where someone was billed $6,300 for a four-hour visit where she spent most of that time sitting in a room by herself with a monitor draped around her neck. And that was 10 years ago. Yet, there are community health centers where one can be seen and treated for $20, or less. I’ve even had minor surgery at one of these centers, performed by a doctor, for $20. I can’t imagine what the same procedure would have cost had I gone to a hospital or private clinic.

Costs can also vary enormously, depending on whether one has insurance, the kind and terms of the insurance, is on Medicaid, pays cash, pays on time, or doesn’t pay at all. All these factors, which go to the heart of how our healthcare system is run and costs are assigned, guarantee these results. And the problems go beyond healthcare, reaching down into our educational system, where the outrageous costs of medical school cause medical students to run up enormous student-loan debt, often of a quarter of a million dollars and more. While eventually many of these medical graduates will earn significant salaries, the salaries for recent graduates and residents are a far cry from generous, falling in the range of $51,000 to $66,000 per year, before taxes, for an 80-hour work week. Taking that $51,000 figure, a new doctor working 48 weeks a year is averaging $13.28 an hour, less than many retail employees.

While the House, the Senate, the Administration, the Congressional Budget Office, and commentators on all sides of the current healthcare debate parse the finer points of the various bills and proposals on the table, the bigger issues seem to be lost in the cacophony. I can’t help but think that the special interests, the insurance companies and industry lobbyists, are given more consideration than the lowly patient. And whenever one hears the word “comprehensive,” it’s time to run for the exits since the fix is almost certainly in.

Perhaps the biggest issue of all concerns the near-complete divorce of healthcare costs from market forces. Healthcare providers, whether hospitals, private doctors, diagnostic labs, or clinics, are essentially businesses and, in aggregate, they form an enormous industry. In what other business or industry are costs not known, not set out in formal tariffs or schedules, and not subject to public scrutiny? Even airlines, for all their multitudinous fares and conditions, are forced to lay out their tariffs, and before customers buy tickets they know exactly how much they will cost.

While government regulates – to various degrees of effectiveness – the nature and quality of healthcare and medical practice, it does little to promote market forces. It is my contention that any healthcare provider should be required to post the rates or costs for any given procedure, action, or item. Even if there are different tariffs for different methods of payment, the consumer will at least have something to go on in deciding how and where to spend his or her healthcare dollar. And this will inevitably lead to price competition between providers and a brake on upwardly spiraling costs.

This divorce of healthcare costs from market forces also stems from how many Americans obtain their insurance, which is paid for or subsidized by their employers. There is no incentive for many Americans to price around (even if they could, given the price morass) and obtain the best bang for their buck. “Oh, the insurance will cover it,” is often the refrain. Now some insurance policies and plans do enforce certain limits on what providers within the plan can charge or be reimbursed for, and that helps control costs to some degree, but there is often a downside to the insured.

One downside is a limitation of choice, but the other side is the cost of administering these various insurance plans, approvals, billing, and so forth. In the U.S., 25% of healthcare spending goes to administrative costs. A full quarter of what we spend on healthcare. In our neighbor to the north, Canada, the administrative burden is half that – 12% – and most other countries have far lower administrative burdens than ours. Perhaps the only country that comes close to our burden is The Netherlands, with a 20% administrative burden.

While the U.S. often is criticized for lack of public support for healthcare, in fact our governments, federal, state, and local, spend more on healthcare than that spent by the governments of most other OECD countries. Overall per capita spending on healthcare puts the U.S. at the top of a list of 13 high-income countries – more than $9,000 per year, nearly three times the OECD average and more than double the next biggest spender, France – it is also near the top of the list of countries in public per capita spending on healthcare. Only Norway and The Netherlands spend more public funds on healthcare than the U.S., while Switzerland and Sweden rank just below the U.S. In fact, per capita public spending on healthcare in the U.S. is a third higher than in Canada.

What this indicates is that the U.S. does – and doesn’t – have a spending problem when it comes to healthcare. We’re certainly spending much more than what other countries are spending on healthcare overall, and even our public spending on healthcare exceeds what most other countries spend. But we’re not getting the results of some other countries in terms of total coverage of the population. And while it’s true that U.S. health results, measured in terms of life expectancy, infant mortality, and some other indicators, are below those of other countries even with our high outlays, there are mitigating factors influencing those results that are not as present in other countries.

By most standards, the quality of care in the U.S. is good, even excellent. And compared with other countries – including, again, our neighbor to the north – waiting times to see doctors, referrals to specialists, and to receive diagnostics and operations are significantly lower overall, though these can vary significantly from one area or region to another. While gaining access to the healthcare system can pose a challenge to many Americans, once that access is gained things tend to work pretty well, and better than in some countries with so-called universal coverage.

So where do we go from here? Okay, I have some ideas. These are my proposals, and while I can’t cite empirical data supporting their efficacy, I think they merit serious consideration and may allow us to gain control over this nationwide shell game:

● Introducing market forces by requiring all healthcare providers to develop, publicly post, and operate under specific costs and tariffs;

● Instituting public oversight of costs and charges of healthcare providers, including hospitals, clinics, private practitioners, and diagnostic labs, and allowing private suits and administrative processes challenging unreasonable or unsupportable costs;

● Encouraging individual initiative by expanding health savings plans where people can set aside a portion of their income to be applied to healthcare costs, and allowing them to roll over funds not expended from year-to-year;

● Encouraging employers to offer their employees allowances which employees can use to shop around and acquire their own insurance plans (often at lower cost than group policies), and further allowing tax deductions to cover insurance premiums and other healthcare costs;

● Allowing insurers to offer a variety of plans covering a range of services, and not requiring services that a given insured determines he or she is unlikely to need, such as mental health services or pregnancy coverage;

● Not restricting insurers to certain states but allowing them to operate across state lines;

● Taking steps to reduce the administrative burden and associated costs;

● Directing greater public funding toward community health centers and using these centers to provide health care, on sliding cost scales, especially to lower income and uninsured parties;

● Encouraging formation of healthcare cooperatives, both private and public, and allowing both insured and uninsured people to join them;

● Developing public policies and pressure to reduce the cost of medical education;

● Allowing write-offs of most or all debt or costs incurred by medical students in return for a certain period of service, at reduced salary levels, in rural and other under-served areas (as is done in some countries);

● Developing policies increasing the numbers of medical, nursing, and allied health students to address national shortages in these fields, applying the law of supply and demand to reduce costs and improve access;

● Applying both public and private initiatives to controlling the cost of pharmaceuticals;

● Instituting reasonable limits on medical malpractice claims to help contain the cost of malpractice insurance.

Again, I don’t claim to be an expert on healthcare, and I don’t claim to have all the answers. But I think these steps could go far toward expanding access to healthcare, controlling costs, and getting the runaway train of American healthcare back under control, without further straining public budgets. And it’s time we put a stop to the shell game inherent to the American healthcare system.

I welcome comments, criticisms, and other suggestions to what is said and proposed here. And please share this posting with your social networks and others who might have interest in the topic.

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