Loren Pechtel

Yeah, they wanted you to have tried Claritin before they approved Zyrtec. You tried it, it didn't work, ok Zyrtec approved. That's how it should work. The nurse probably didn't trust things to work as they should.

Dr Rick

Thank you, but let's not get carried away, now; I'm certainly not dismissing what you have posted, and I suspect much of your knowledge on this issue complements mine.

I too am of the opinion that tort reform is badly needed (have you ever heard of a physician that wasn't? ), but I think the issue has been used by some interests to seriously obscure the crisis in health care financing or to pervert the debate into one over malpractice reform.

The crisis in mi (it may seem that I am using the term crisis excessively, but I'm actually a pretty calm guy in an emergency. I really do believe that healthcare financing is in a state of crisis nationwide, and torts and mi are part of that crisis.) has severely impacted healthcare in certain areas such as Las Vegas, portions of Virginia and Pennsylvania, and others, and in some critical areas of care; especially trauma, obstetrics, and neurosurgery. Many hospitals and practices have had to curtail services or close because of skyrocketing mi rates. Tort reform would alleviate the damage in those "hotspots," but it will hardly make a dent in the overall healthcare budget and will do little to improve access to healthcare except in limited areas and specialties. Healthcare financing reform, much more than tort reform, is imperative if we are to get the working-poor, retirees, the disabled, and increasingly the middle-class adequate access to healthcare.

You are absolutely correct. Fixed caps, or budget freezes, do nothing more than force providers and hospitals to treat fewer and fewer patients. It's what the federal government has done with medicare, and it's been a disaster. Medicare re-imbursement has been actually decreasing over the past 2 years because the fixed amount of money in the medicare fund is being stretched to cover more seniors and more procedures as costs rise. Has a result, more and more doctors are turning-away medicare enrollees. Similar problems long ago began in medicaid, for slightly different reasons (Medicaid reimbursement was crappy to being with).

In my practice, only me and two of my partners out of 7 of us are taking new medicare patients, and only two of us are taking any medicaid patients at all. Reimbursement cuts have been specialty-specific, and in my field of gastroenenterology are slated to be as much as 20% for some of the procedures I do. The proposed cuts are currently on hold due to litigation by my specialty society which is of the opinion that doctors shouldn't lose money for taking care of retirees. If the cuts do happen, I might have to start "balance-billing my medicare patients, not an appealing thought as many of them are on fixed incomes.

Don't get me wrong; I love the practice of medicine, but I don't think that I should have to pay to do it.

We really have no choice; the rising costs of healthcare in the US will soon consume so much of our GNP (currently it's at 12 to 13%) that we just won't be able to afford any other alternative.

Before someone objects and points-out the problems of medicare and medicaid as an example of US government medical coverage, let me remind you that the reason these programs are financial wrecks is that they operate without any cost controls, and despite the problems, medicare enrollees are still getting good care.

The problem with these programs is that they have fixed caps, which limit reimbursement, but no effective way to control the actual cost of healthcare delivery, and as long as we have a population with inadequate and inequitable insurance coverage, that will always be the case. A universal healthcare system in which coverage for everyone is assured would allow medical services to be efficiently rationed. Rationing of health care may be anethema to some Americans and American companies, but it is necessary and the only way to keep healthcare costs under control. Certain procedures done on certain people for certain things just aren't cost-effective. Healthcare could be effectively rationed without negatively impacting the quality of care, and that's how the Germans, Canadians, Swedes, and English do it. Their systems all differ in many respects, and each as its problems, but common to all of them is good healthcare for everyone at less than half the price that Americans now pay. They can do it better than us because they can control the re-imbursement and the costs, and not just one or the other.

Universal healthcare coverage proposed in the early 1990's was soundly defeated by the collective propaganda of short-sighted physician, hospital, and insurance cartels. They'll likely howl again, but sooner or later the screams of desperate employers, workers, retirees and the ever increasing number of uninsured Americans will drown them all out.

auto-da-fe

do you think it should be state regulated (like medicare and medicaid thanks to Mr. Clinton), or do you think it should be federally regulated? Have you given any thought to that actual technicalities of implementing such a healthcare policy? for instance, what happens to all the millions of HMO policies out there (or any other major medical policies for that matter)? and what exactly should the government cover? eye care? dental? disability? or just medically neccasary procedures?

Loren Pechtel

The problem is that too many of us have seen how monopolies stink and how the closest equivalents to universal health care here (medicare/medicaid) stink.

I like the idea of universal health care but until I see evidence that it wouldn't be a disaster I'm sure not going to support it.

We've also seen how cost containment works with HMO's--the cases that aren't clear get brushed aside. (An example I ran into some years back: Boy, 3? 4? with belly pain after eating, no apparent cause. Multiple times at the doctor produced no useful results. It happened once when they were visiting us. My wife looked at him and figured it out: worms. Since she's an oriental doctor, though, not western, she has no prescription pad {she is trained in acupuncture and herbs, not western pharmacology}. The mother still had to make a scene with her doctor to get him to order the test that would confirm what my wife found. While the oriental approach might not be as precise as the western she's trained to observe rather than rely on the lab. My father might still be around if he had listened to her. She said there was something seriously wrong with his kidneys. He wouldn't listen, after he left she said he wouldn't be around to come to visit next year. 5 months later they removed a baseball sized tumor from one, then found another inoperable tumor.)

Dr Rick

...first, tell us your thoughts on this; same for everyone else.

Do you agree or disagree with some or all of what I've said so far? What do you think we should do for the over 50 million Americans that will have no healthcare coverage within ther next 3 years?

Rick

Dr Rick

What's more of a disaster: Canada's or America's healthcare system? Who pays twice as much for the same quality of and in some cases slightly worse care by all objective standareds (mortality rates, vaccination rates, infant mortality, etc..)?

auto-da-fe

well there are some pros to america's current healthcare system as compared to canada's. more personal choice springs to mind immidiatly.

Although if you are talking strictly financial and sustainability, then canada is definitly above america. as you have already pointed out, if something doesn't change about our healthcare system, then we are certainly in trouble at some point in the future, where as canada's health care system looks as if it could be maintained almost indefinatly.

Dr Rick

One of the putative advantages of the American healthcare system is that it is supposed to allow more choices, but I wonder if that's more illusion than reality. In my case, like most Americans, I get my healthcare coverage through where I work. I'm a partner, meaning I am a part-owner, so I have at least as much say if not more than most people in what plans we choose, It's up the physican-owners to vote on which insurance choices we'll offer to ourselves and our employees, but if I or anyone else doesn't like the majority outcome, that's just tough.

For most of you choices are even more limited. Typically, an employer is the one that decides what plans you and your loved ones will be offered, which in turn dictates what providers and facilities you may use, what services you may get, and how much you must pay out of pocket. Realistically, most of us cannot afford an out-of-network provider or facility on our own, and cannot afford many of the newer drugs that may not be covered by an insurer's formulary. So our choices are really not as unlimited or easy as one might at first glance believe them to be.

In America, we have more choice, it's just that we must almost always "choose" to let our employers and insureres make many of the decisions for us.

Have you ever considered the rationale behind offering insurance through employers in the first place; that is by far the most common way we get our insurance in the US, but why? Why should our employers, and not our landlords or bankers, or for that matter our grocery stores or gas stations, make those decisions for us? What's so special about employer-based insurance that it is the norm in the US? Our employers don't really pay part of our insurance so much as they withhold part of our earnings to cover it, so the whole thing is essentially a financial wash. Most of us, though, can change bankers, grocery stores, gas stations, and landlords more easily than we can change jobs, which would actually give us more or at least easier choices, there's no reason those entities couldn't negotiate insurance contracts just as well as our employers since they are employers anyways, and a customer-based system rather than an employee-based system would allow more people (such as the self-employed and the part-time employed) access to group health insurance plans that they do not now enjoy.

Of course, I don't really think that selling insurance out of Wells Fargo or Exxon is the answer to our healthcare woes,, but I hope it illustrates that employer-based insurance shouldn't be considered sacred or particularly wise, even in a semi-privatised system such as ours.

In retrospect, employer-based insurance wasn't a very well thought-out idea; in fact, it wasn't really thought-out at all or planned by anyone with any interest in healthcare. It was an accident of history, and that accident was World War II. Before the 1940's, most people didn't carry health insurance, and medicaid and medicare were still decades away. But wiith the war came wage and price freezes, so more and more employers began to look for non-monetary incentives to hire and retain employees in the tight job market, including offering health insurance. The war didn't start the concept of employer-based insurance, but by the fifties, most employers were offering it.

With the actual reimbursement for healthcare now handled by third-parties instead of the consumer, or patient, one of the primary market forces that keeps capitialism so efficient was lost to the field of medicine and has never been recovered

openeyes

I don't know for sure if you plan would've covered Zyrtec in November when the rx was written, but many plans changed their rules concerning coverage since Claritin went OTC. As far as I understand it, the in-clinic pharmacy would have to get the prescriber to get the same sort of authorization that we at the off-site pharmacies would have to obtain.

I could go on about how implementing the rules of all the various plans consumes so much of our time, but I need to get to work (overnight pharmacist) and have my time consumed!