My purpose is not to destroy profit centers in
medicine...

Exactly why do we need "profit centers"? The US existed for a long time with non-profit insurance companies, non-profit hospitals and medical practices that made their doctors a decent living, but weren't "profit centers".

If you are going to adopt the libertarian/conservative view that everything is for sale, including people's lives and health, than I think you are addressing the wrong audience.

The idea that everything in this country should be a "profit center" has gone too far. We have public roads, lottery systems, prisons, and even wars being turned into private "profit centers".

There is a reason why people join together for the common good. If everyone is in it for their own personal aggrandizement we might as well retreat back to our own personal (heavily defended) caves.

Of what value does the 30% overhead have to the health system? How did the $1.8 billion options and pay package of the former Unitedheath CEO help the participants? And how much additional health care could have been provided by the $1 billion in profits they made in just the most recent quarter?

Do the right thing, or don't do anything.

--- Policies not Politics
Daily Landscape

Again, I do appreciate your engagement on this.

Single Payer proposals are the most open and fair and negotiated proposal.

Single payer, as proposed by HR-676 led by John Conyers, and including the chair of Ways & Means (Rangel) and chair of Ways & Means Health subcommitte (Stark) as co-sponsors and also the original "Doctors propsal" from Physicians for a National Health Program as published in New England Journal of Medicine are the most open and fair in setting what is covered and what reimbursement will be etc. I urge you to actually read the details here:

http://www.pnhp.org/facts/single_payer_resources.php

“Of course all of this misses the point that medicine shouldn't cost me anything.”

Do you expect those who take care of you to work for nothing or do you expect someone else to compensate them for their services?

I expect a publically financed program. So I'd pay, yes, but through taxes.

thosethingswesay.blogspot.com

Are you using the price-per-pill as more as a metaphor for the whole topic of transparency, or do you consider the unit dose cost for drugs a major part of healthcare cost? If the latter, I wonder if it is being overemphasized, with all due respect to the cost of drugs, especially outpatient maintenance drugs, being a large part of the healthcare economic problem.

Let me take a current drug cost, safety and efficacy issue: two oral diabetes drugs of the thiazolidinedione (TZD) class, Avandia (rosglitazone) and Actos (piaglitazone). My last endocrinologist did not want to prescribe any drug in the class, given that there have been safety concerns in the presence of heart disease. Some months ago, with a different physician, I added rosglitazone, and got a huge improvement in diabetic control. The MSM have been trumpeting a major safety warning about rosglitazone, sufficiently of concern that the FDA convened an expert panel on safety, which voted 20-3 to leave it on the market.

If one reads the actual research, the safety issue is not as black and white as some have had it, although it's probably safer in men than in women. We changed to piaglitazone for additional reasons including some additional therapeutic benefits.

Turning to transparency, however, when I look at wholesale prices for the two drugs listed on Medscape, the monthly cost for my dose of the older drug ranged from $266 to $366. For the newer drug, the range is $385 to $560.

Do you consider it more important that there is such a range for each drug, or that of the two drugs, one is consistently more expensive than the other? Remember, these are drugs that very well may be prescribed indefinitely, and have a measurable effect on outcomes.

I don't want to suggest these drug costs are trivial issues. To me, there is also as much significance in the decision to use any TZD drug, with insulin, as to use insulin alone. In my own case, there are objective benefits to adding an expensive drug. While I'm not a physician, I can compare the detailed risks, benefits, and costs. I pulled the relevant research reports for my physician, did additional statistical analysis, and we arrived at what was a joint decision.

But what if someone were prescribing for my Aunt Shirley, whose prompt departure from the planet would be cheered by all? Again assuming that the patient were totally dependent on physician expertise, what if it were Nelson Mandela?

Moving away from drugs, how does the cost-shifting caused by EMTALA-mandated treatment of a uninsured victim of a drive-by get improved through transparency? Do you see the whole issue of cost-shifting being brought to the fore by transparency? What about Medicare DRG reimbursements that cover the average, but not complicated, case?

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

I have not thought about this idea in super great detail but I think it has some merit. There has definitely been some antitrust litigation in this area over pharma's pricing to medical benefit companies vs. more traditional pharmacies, and we have "one price" rules in other areas like tender offer regulation. "MFN" i.e., most-favored nation, clauses are often found in treaties and other arrangements. I have heard about something in antitrust law like the Robinson Patman law that somehow relates to this but it is not my field of expertise.

I like three other things about it: 1) it is not price controls; and 2) it fosters simplicity which is important to cost containment; and 3) it sounds fair which is not always true of many proposals in this field.

Thanks again, DrSteveA, for continuing to listen to different points of view.

And kindly understand that I'm expressing here the strongly independent views of not only my patients in Northeast Wisconsin, but also the 650,000 constituents I have the honor of representing in Congress.

We respectfully disagree with your opinion that a "Single Payer" system is "the most open and fair in setting what is covered and what is reimbursement..."

My patients are not interested in giving away any of their rights or their freedoms. They want their freedoms back.

They want to have the freedom to choose their own doctors. The freedom to decide what is best for their own family's health - in consultation with their own personal physician(s).

They are NOT interested in government employees taking away any of their freedoms. They are NOT interested in experiencing another "Decider" in government - one who will decide who lives and who dies.

People in Wisconsin and all across these United States tell me repeatedly they are NOT interested in government controlling their most personal health care decisions, and are NOT interested in having a government official, or a committee sitting behind closed doors, "negotiate" on their behalf or decide the fate of their family's health.

What people want is the freedom to go to their own doctors - at prices they can afford to pay.

Health care in America is all about access and affordability, just as mush as it is about quality, price and service.

The bottom line is that a Single Payer system in health care would be a loss of personal freedom.

So, please allow me to share with you a portion of my day and how it relates to Unitary Pricing.

UNITARY PRICING - AND THE DIALYSIS CLINIC

Today, I visited with the doctors, nursing staff, and patients in a dialysis clinic in my District and listened to their concerns. Their most urgent problem is the impossible cost of a prescription drug to lower serum calcium levels. In Shawano, WI, the pill costs $500/month, and without it these kidney failure patients may not survive. In this economically challenged rural area of Wisconsin, $500 is a ton of money, and it is well beyond the ability of these patients to pay for it out of pocket.

The prescription drug is NOT available as a generic, and if Medicare, Medicaid or a private insurance company does not come up with the money, these patients with kidney failure may not survive.

Guess what? The identical pill - from the same manufacturer - costs far less in Mexico City and Canada than it does here in Wisconsin.

When we enact a law to estasblish UNIATRY PRICING, a drug company will be allowed to set its own price for their pill, and then the lowest price they accept as full payment from any customer will become the price every other Citizen shall pay - just like at a restaurant when we order from of a Menu.

We need a Medical Menu where every Citizen receives the same product or service for the same price - a price set by the seller of the product or service. This is NOT price fixing or price setting; it is allowing the open marketplace to do its work.

we must establish Open Disclosure of all prices in health care, and then allow UNITARY PRICING, so every customer pays the same price.

When we simultaneously establish (1) Open Disclosure with (2)Unitary Pricing across the nation, we will begin to finally leverage down prices for all of us.

UNITARY PRICING - AT A TRIBAL CLINIC PHARMACY

After visiting the dialysis clinic, I had the honor to meeting with the leadership of the Menominee Nation in Keshena, Wisconsin.

There I learned about one of the few benefits First Nations enjoy: they are allowed to purchase prescription drugs at the same discounted prices negotiated by our VA hospitals and military pharmacies.

When we enact Unitary Pricing, every Citizen everywhere in these United States will be able to buy their prescription drugs at the lowest price negotiated anywhere - including the VA or the Tribal discounted prices. And yes, even the prices being charged in Mexico and Canada.

With Open Disclosure and Unitary Pricing, every Citizen wins.

Hi destor23.

I agree that the best price for anything is zero, but based on most everyone's common experiences, you get what you pay for. And if you do not pay for it, it will be gone.

With enactment of OPEN DISCLOSURE and UNITARY PRICING, every doctor, dentist, drug company, insurance company, hospital, chiropractor, et al will set their own prices for whatever they are attempting to sell.

All we are asking is that they OPENLY DISCLOSE the price, and then accept as full payment the same amount from every Citizen.

This is what I refer to as UNITARY PRICING.

Show me the price and charge every customer the same.

The bottom line is that a Single Payer system in health care would be a loss of personal freedom.

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

That's correct.

We will pay less and others will pay more.

We have financed the health care for other nations for years.
It is time to take care of our own.

Define mess. The only mess that I'm aware of is the recent provisions to provide drug coverage that were a hodge podge of donuts and no coffee to go with it.

What was a simple plan for the patients has become difficult to figure out because the program keeps getting diluted by allowing more and more private insurance programs to take part.

As for the physicians, I'm sure they don't like the fee schedules, but unlike the patients they have plenty of organized strength to make their issues known to lawmakers. If they are doing a poor job of this then they better hire some new lobbyists.

And please don't throw in the red herring of telling people that the government will tell you which doctor to go to. Don't insurance plans already do that? If you are in an HMO you are really restricted. If you have a regular plan and you chose to go "out of network" you pay through the nose. So what's different?

Then there is the case that Medicare won't pay for some treatment because it thinks it is unproven or the results aren't worth the cost. Don't the private plans do this as well? In the UK they have a formula where treatment is evaluated on additional quality of life years and if it exceeds the limit, you are on your own.

No system can pay for everything and in this country people are unwilling to face up to the fact that sometimes there really aren't any good options and you should just prepare to die. Other societies understand this. Here we get desperate hail Mary appeals for untried drugs.

The government can collect the premiums and pay the fees more efficiently that can for-profit firms. If you don't like the enabling legislation then set them different payout criteria.

--- Policies not Politics
Daily Landscape

I don't understand the point of disclosure if the price is fixed. And disclosure is fine, but what costs are not dislcosed on request? Costs to whom? And good luck getting price controls past the Supreme Court, although they did decide it was OK for private enterprise.

I'm of course sympathetic to liberal views (I'm liberal, hey) but I find no explanations here, only ALL-CAPS assertions of the good things that will come.

Suggestion: converse, don't shout; explain, don't chant.

“Suggestion: converse, don't shout; explain, don't chant.”

And stop repeating the “Big Pharma, Big Insurance” slurs ad-nauseum…once was enough, I get it…you don’t like them. Constant repetition makes it seem like you are more interested in scapegoating than fleshing out your ideas.

Oh, I agree that decent palliative care is generally available today, although it's sometimes necessary to fight for it. As far as religious hospitals, it will depend on the religion and/or the particular religious group running things. In that context, I've had the most experience with a Jesuit facility, which I found took "no heroics", in the case of adults and some infants, seriously. Their ethics committee dealt, fairly early, with the understanding that opioids, properly used for pain control, are licit under Aquinas' Principle of Double Effect. Such use is not euthanasia.

Your point is well taken, given the Schiavo fiasco. GWB's intervention in that case is ironic given his signing the Texas Futile Care Act. One controversy regarding that Act involved withdrawing ventilation from a terminal cancer patient, Tirhas Habtegiris. The Habtegiris case was, bluntly, a mess, as have been others, not all in Texas, involving objections to stopping ventilator support. One of the most searing descriptions, unfortunately not online, was that of a fully aware cystic fibrosis patient who literally fought off his nurse and mother trying to force a bag-mask-ventilator onto his face. My own advanced directive authorizes stopping futile ventilatory support, but with explicit directions on terminal sedation that makes it a humane procedure.

Back in the seventies, quite a few of the problems came from unwillingness to address end-of-life care. While my mother was in a community hospital, medical oncology, outside an academic facility, was new, as was my durable power of attorney--respected there, but not at VA. I didn't like being in the position, but the feud between the oncologist and the primary physician resulted in my playing referee. One day, my mother called me, complaining of nurses giving her uncomfortable IVs saying they were "to build her strength". This didn't make a lot of sense, and I used my chart access to find out the real picture.

She was having a drug reaction, which was causing her calcium level to rise rapidly. The primary physician/cardiologist (never trust a 350 pound chain-smoking cardiologist) had gotten his ego involved, and decided to take fairly drastic measures to try to reverse the reaction. As I confirmed with the oncologist, not treating the reaction would cause lethargy and death.

Unfortunately, none of the staff presented the options to my mother. She was still competent, although upset, and I felt it my obligation to give her the facts. I told her that I would support whichever choice she made: try the one remaining treatment that might buy a few months, or stop the treatment and die gently. While I had my own opinion, I didn't think it was appropriate for me to make the decision. She chose to try the last option.

Unfortunately, she hit the lifetime cap on her private insurance, and, as a retired Army officer, went to a VA hospital, which was clueless about pain management and resistant to any family input, even with power of attorney. She was twice resuscitated from cardiac arrest, with a third attempt failing due to a lack of staff.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

I don’t think that Kegan is advocating price controls ala Nixon. Seems like individual companies could set prices as they pleased but could not offer quantity discounts, for example, since prices would be required to be the same for all. I’m not sure what the advantage of that is, but I haven’t studied it much.