Re: ot: health care- drawing the line and controlling costs

ed stated in post
36679578-b469-4cdb-975a-16c98d1fd310@xxxxxxxxxxxxxxxxxxxxxxxxxxxx on 9/13/09
11:04 PM:

....
you're jumping to conclusions about what i wouldn't allow in my
system.  for the sake of discussion, let's assume things are largely
as proposed by obama, with my comments added on.

Without digging through the thread, was your idea not to deny coverage for
people who refused to follow their doctors orders?  If no, then please
clarify.

as already clarified, denied for those things that are a result of you
refusing to follow doctors' orders.

I had not read that clarification when I posted the above. Good to see you
at least only want to limit some care... though now there is the question of
how you decide how to figure out what is a result of someone not following
doctors orders and how you know if someone is following those orders. And,
of course, you are implying that it is wrong to not follow the advice of an
expert - sometimes, though, the wrong thing is to follow the advice of the
"expert".

let's also leave kids out for the moment- they're always a special
case.  but let's say you didn't want antibiotics for an ear ache, and
it turns out that it *is* infected, and you lose your hearing from
it.  no cochlear implants, and no hearing aid for you (paid for by the
system).  you can, of course, pay for it yourself.

So if you have an ear infection and chose to treat it in a way contrary to
your doctors orders - even if based on reason and research - and things do
not go well, then you do not get care.

yup- just like you wanted, personal responsibility, no? you'd be
responsible for the results of your actions.

One: people cannot be responsible for that which cannot be predicted.
Two: being responsible does not mean punishing someone and not allowing them
to get care they have already paid for!

to clarify, you would still be covered for something unrelated- if you
break your leg, that's still covered.  now, if you break your leg
because you couldn't move out of the way because you couldn't hear
your dog running up behind you, that'd be a gray area but i'd probably
lean towards letting you be covered anyways (but i could probably be
convinced otherwise).  :D

A whole range of maybes in their... and a bureaucracy to try to decide...
and have to defend its actions.  All while people go untreated.

it happens with any large system.

So why add to it?

But, still, good to see you at least limit the scope of your idea (I do not
believe I had seen you put such a limit on it before... if you did, I missed
that...).  

what, you thought my initial 2 sentence description (w/ a couple more
for questions and examples) would constitute the entirety of a health
plan of some sort? :D

We can argue about blame - but I prefer to accept we have reached a better
understanding. Not interested in dissecting your past words to see if you
did nor did no imply what you now say you meant. You have made your view
clear now... either I misunderstood or you were not clear - or a combo or
just a reasonable misunderstanding with no "fault" to be had. I do not care
which.

Still, why not encourage people to make wise choices based on
their own research instead of forcing them to listen to the "experts"
(balancing that with losing care).

because "encouraging" people to make wise choices means many won't and
we would end up paying for it.

And if people always followed the advice of the experts we would pay for the
mistakes of the experts. I have been in the situation more than once where
if I had followed the advice of a doctor it would have been the wrong
thing... I have also followed bad advice and paid for it.

If someone goes against the advice of the experts and it works would you
award them a bonus? I bet not - but you want to punish them if things go
wrong and not reward them when things go right.

this allows us to cover those as medicine deems best; if people don't want to,
they go without, or pay for it themselves. you can make the 'wisest' choice
for yourself within those constraints (cost, care, consequences).

Why put artificial punishments (but, presumably, no rewards) on people not
following "expert" advice like sheep?

i.e. you're cut off "free" care- you can still pay for whatever you
want...  if you can afford it.

Sigh... of course I was speaking in the context of the discussion of public
care.  Do you or do you not think people should lose such care if they take
responsibility for themselves and do not blindly follow a doctor's orders?

to clarify, you'd lose coverage for things directly related to what
you disregard.  you feel you know better, well, if you do, you should
be fine.  if you don't, well, you pay the consequences- the ultimate
responsibility, no?

There is no guarantee in any treatment.  Ginger often works as well or
better than Dramamine, but there is no guarantee.  Vitamin C and/or
magnesium and calcium often work very well for constipation - but no
guarantee.  If a doctor pushes you take a medication you know is more likely
do harm (as was clearly the case with many of the meds that are now off the
market) and you opt for the better choice (or at least what research leads
you to believe is better) but it turns out your problems were tied to colon
cancer, do you deny the person coverage for that because it was tied to the
same set of problems?

that example would clearly not be directly related to the advice yo
disregarded- the cancer was there regardless of the care chosen, and
not caused by not taking the recommended action or taking alternative
action.

But the care you were seeking was based on the same problem - so now you
need to find cause and effect - not just "related" things. OK. That at
least makes more sense... but how do you show cause and effect? How do you
show a 450º patient is eating 10 Twinkies a day? Make him keep receipts?

 Where do you draw the line?  Can you give a few
specific (though hypothetical) examples of where you would deny care?

i already did (mole/cancer/chemo, antibiotics for ear/cochlear
transplant) but i'll give some more - steve jobs wanted to to use
alternative treatment for his pancreas issues for 9 months, but it
didn't work? no surgery paid by the system!

And if it had worked would he have been granted the cash he saved?

And can you prove his doctors suggestions would have had a better outcome?
For that matter, are you sure his doctor did not approve of the treatment
plan he decided on.
And what if the first doctor he went to did not approve of the plan but the
second one did, when he got a second opinion? A third? If he is not
following the plan of the first doctor, would you even allow him to get that
second opinion (in the system... I know Jobs could pay for it on his own).

you weigh 300lbs and the doctor told you to lose weight, now you weight 400lbs
and have type 2 diabetes? tough noogies.

Even if you are depressed, have an eating disorder, and are on meds that
lead to weight gain? Even if you have hormone imbalances that lead to
weight gain? Even if the patient denies eating poorly?

How do you know if the patient was or was not doing what they could?

 You can make it easy on yourself and point to a diabetic on the all-Twinkie
diet, but even then their will be cases where you do not know it
complications are related.  And how do you know what people do in their
private lives?  How do you prove the diabetic is eating 10 Twinkies a day?

you can't (and if you can't, you cover them), but you can tell if you told
them to lose weight at 300lbs and now they weigh 400.

And you automatically assume a weakness in character for that? A lack of
taking responsibility. In some cases, sure... but in all - hard to show!

....
regarding the ear infection, yup.  i don't get why you think that
gives up someone's responsibility.  you're *ultimately* responsible-
if it doesn't work out, you're responsible.

So if the infection spreads the person is without care for, say, a bone
infection... even though they took a prudent and reasonable course of
action.  

if it's directly attributable to not taking the antibiotics (i'm not a
doctor, so i don't know if that's possible), yup.

But you do not know if the antibiotics would have prevented it. Medicine is
funny that way. Maybe with the antibiotics it would have spread to the brain
and been worse.

....
again, you're jumping to too many conclusions- to clarify, think of it as
what obama proposes.  with my "line" added on.  when necessary, think "what
would be most likely"- this will differ, but i think we can agree it's most
likely nothing would be instantaneous or there would be no option to
contest.

So if you are denied care for refusing to follow orders from one doctor you
can still go to another?  Or not?  Or only for the concern(s) you had when
you were deemed to be going against doctors' orders?

sure, within limits (like under any insurance system); as i said, think of it
as the same as the current system (or obama's proposed), with this one
stipulation. i'm not aware of any system that doesn't allow a second opinion.

But if you are denied care for not following doctor's orders, then you
cannot get a second opinion. What if I am given orders I think are bad and
am waiting to see another doc to get another opinion, and during that wait
something bad happens (related, of course). Does the second doctor get to
step in and "guess" what his orders *would have been*?

And if you have not
had the appointment, how does the "system" determine that with any detail?

not sure what you're asking here.

Have complaint.
Go to Doctor A who says follow Plan 1.
You think Plan 1 is the wrong plan... seek second opinion. You think
Doctor B would work with you with Plan 2.
Before you can see Doctor B, something related and bad happens.

If the "related and bad thing" happened after seeing Doctor B, assuming you
are right about him approving Plan 2... all is good. But since it happened
before... toast.

Is that how things work under your plan? If not, where am I going astray?

....
i'm not dodging that- i disagree and the discussion continues.  and
i'm not even sure where you think there would be less responsibility
(in the general case).  you can listen to the doctor, or do your own
thing, including paying for it- the ultimate responsibility for your
care in my mind.

If you do not follow your doctor's orders you are *denied* coverage... which
you have now limited to just coverage for things "directly related"...
something which would be hard to define in many cases.  And as people fought
to show how it was not "directly related" they would, I assume, be denied
care?

of course- just like the system now. (as i've said, when in doubt,
use the current system as a guideline. then add my line.)

But the current system with an added level of red tape... red tape that does
little good and may or may not even save money.

 Or do they get care as the disagreement is decided.

heck no. what health system allows you to get the care you wanted but
were denied while you appeal?

Back to denying care for those who take responsibility for themselves.

 And decided by
whom?  Seems to add a lot of red tape.

no- health systems all have appeals processes in place now.

But you are adding reasons to deny. Vague ones at that.

But even outside of the red tape and personal privacy problems, what about
the responsibility side of it.  Using the ear infection case again, if you
opt for garlic drops, a reasoned treatment for a basic ear infection, and it
turns out you get a bone infection, should you then be denied antibiotics
for *that*?  

it depends- is the bone infection a result of the ear infection? if
so, and the doctor said you should use antibiotics, but you didn't,
yup, denied!

Denied even though you took a reasoned course of action. Why?

again, let's try to have a discussion and not have a meta discussion-
i don't think i'm dodging the above, you think i am- to be sure not to
dodge, do you have a specific question regarding responsibility that i
can directly address?

fwiw, i'd like a direct answer to the question "would you draw any
line where you deny anyone coverage? "

I do not have a solid line - I have already acknowledged you cannot give
treatment to everyone.  Not everyone can have, for example, the newest MRI
available... not everyone can get a needed kidney if supplies are low.
Sucks... but it is true.  I do not think part of the decision, however,
should be based on something that would discourage people from taking
personal responsibility.  I find that horrendous, frankly.

i understand not everyone can get coverage- but the question is would
you ever DENY coverage to anyone that would be available?

Off hand, no. If you can provide the care and do so without denying the
care to someone else, then, sure, give care. The cost will likely be made
up in a more productive population.

There might be exceptions to this... none come to mind. Maybe for people
who are seeking to have every test they can with no medical reason... but
that falls under not offering tests without a reason, something I think we
have agreed the "system" should not do.

For what it is worth, I do realize it lets those who are irresponsible "get
away" with things.  I can understand why that bothers you... of course!
 But there are huge unintended consequences to your "solution".

no, they're mostly intended.  :D

Then we disagree with the goals of health care.  I do not believe it should
be used to push people to follow experts even if they are wrong.

if the health professionals are wrong, and you are right, and you go
on your own path, there is no consequence to you (i.e. you still get
the correct care)!

But not subsequent care for the same ailment, even if treatment needs
change. All in the name of saving some money... though it is not even clear
that would happen.

--
[INSERT .SIG HERE]


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  • Re: ot: health care- drawing the line and controlling costs
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