Skip to comments.Coming: A Two-Tiered Health Care System
Posted on 05/25/2013 7:55:06 AM PDT by Kaslin
I believe we are moving toward two different health systems. Which tier do you think you will be in?
In one system, patients will be able to see doctors promptly. They will talk to physicians by phone and email. They will have no difficulty scheduling needed surgery. If they have to go into a hospital, a "hospitalist" (who reports to them and not to the hospital administration) will be there to make sure their interests are looked after. They may even have an independent agency that reviews their medical records, goes with them when they meet with specialists and gives them advice on every aspect of their care.
In the other system, waiting times will grow for almost everything ? to get appointments with physicians, to get tests, to obtain elective surgery, etc. Patients may find that they don't have access to the best doctors or the best hospitals. They may find that the facility where they are treated does not have the latest technology. In terms of waiting times and bureaucratic hassles, health care for these patients may come to resemble the Canadian system. It may become even worse than the Canadian system.
The evolution toward a two-tiered system was already under way before Barack Obama became president. But ironically, the Affordable Care Act (Obamacare) is accelerating the pace of change. It is doing so in four ways.
First, Obamacare is supposed to insure 32 million additional people by this time next year. If the economic studies are correct, these newly insured will try to consume twice as much medical care as they have been. In addition, most of the rest of us will be forced to have more generous coverage than we previously had. There will be a long list of preventive services that all plans will be required to cover ? with no deductible and no copayment ? and commercial insurance will be required to cover a great many services previously avoided (including, everyone must know by now, contraception). These two changes alone will boost the demand for care considerably.
On the supply side, there is really no provision under Obamacare to create more doctors. In fact, the supply of doctor services is likely to decrease because of two more features of health reform. Doctors, who are already weary from third-party interference in the practice of medicine, will step up their retirement dates as they contemplate the prospects of even more bureaucracy. Also, hospitals are acquiring doctors as employees at a rapid rate. Indeed, more than half of all doctors are now working for hospitals. When doctors quit their private practices and start working for hospitals, they reduce the number of hours they work. (Forty hour work weeks and golf on the weekends replaces 50 and 60 hour work weeks.) Since they have a guaranteed income, they also become less productive.
These four changes add up to one big problem: we are about to see a huge increase in the demand for care and a major decrease in the supply. In any other market, that would cause prices to soar. But government plans to control costs (even more so than in the past) by vigorously suppressing provider fees and the private insurers are likely to resist fee increases as well. That means we are going to have a rationing problem. Just as in Canada or Britain, we are going to experience rationing by waiting.
Consider how much waiting there already is in the U.S. health care system. On the average, patients must wait three weeks to see a new doctor. In Boston, where we are told they have universal coverage, the average wait time is two months to see a new family doctor. Amazingly, one in five patients who enters a hospital emergency room leaves without ever seeing a doctor ? presumably because they get tired of waiting.
All this is about to get worse. Waiting times are going to be especially lengthy for anyone in a health insurance plan that pays providers below-market fees. The elderly and the disabled on Medicare, low income families on Medicaid, and (if the Massachusetts precedent is followed) people who acquire health insurance in the new health insurance exchanges will find they are financially less desirable to providers than other patients. That means they will be pushed to the end of the waiting lines.
Those who can afford to will find a way to get to the head of the line. For a little less than $2,000 a year, for example, seniors on Medicare can contract with a concierge doctor. These doctors promise prompt access to care and usually talk with their patients by telephone and email. They serve as an advocate for their patients, in much the same way as an attorney is an advocate for his client.
But every time a doctor becomes a concierge doctor, he (or she) leaves an old practice serving about 2,500 patients and takes only about 500 patients into the concierge practice. (More attention means fewer patients.) That means about 2,000 patients now must find a new physician.
Because the two tiers of health care will compete with each other for resources, the growth of the first tier will make rationing by waiting even more pronounced in the second tier. As a result, waiting times in the second tier could easily exceed those in Canada.
I also believe all this is going to happen much more rapidly than anybody suspects.
It’s the communist way, comrade
the party elite never had to wait in line or suffer without medication
just wait until someone over 70 tries to get some IRS clerk to approve hip replacement or chemo, especially if their personal records are flagged with any conservative affiliation
1. Wait in line, wait several months, wait for the bureaucrats to decide your fate, crappy, one size fits all, costly and very wasteful, government run, taxpayer paid service care.
2. Out of pocket service care that only the rich can afford. If you really need that surgery, then pay up!
Logically, the author’s projections make sense, and would be the normal economic response. However, we in the US have a hangup with this thing called “fairness.” It wouldn’t surprise me to see legislation forbidding this type of behavior, because it “unfairly” advantages people who have more money.
How could such legislation proceed? I’m not sure—but one way would be to forbid doctors accepting insurance payments from having any sort of side contract for additional service.
Of course, people of means will eventually find a way to pay for better service. There are already the beginnings of medical tourism for elective surgery. My crystal ball says that offshore medical clinic ships will become a reality. Medical care on those ships will be like gambling on a cruise ship, where the slots are turned on and the wheel starts to spin once the boat is 12 miles offshore.
They will outlaw tier 2.
For those who remember the old Soviet Union, it was a grim place at least for average citizens. But not so for those in government. Contrary to the official ideals of equality and a classless society that the ruling communist regime espoused, the USSR created a privileged class of party members inside government the nomenklatura.
This semipermanent bureaucracy earned higher incomes, got better health care, ate better food and had greater job security than average Russians, the much-despised proletarians. Today, our bloated government seems, in significant ways, to be creating this same dynamic.
I will, of course, be on the lower tier, but that doesn’t mean my doctor won’t call me. He loves to talk over the phone. He’s never met my wife, but they can talk for an hour when he calls. I haven’t given him my email or cell phone number.
That thought out of the way, the leftnuts wanted Obamacare because they thought it would mean free healthcare for everyone, no more discrimination between rich and poor, and all that crap. When everyone discovers they are paying more, a lot more, and getting less at twice the hassle, people are going to want something else. The rich will still have quality healthcare, but the poor will be reduced to lab rats being tortured by bureaucrats.
“These doctors promise prompt access to care and usually talk with their patients by telephone and email. They serve as an advocate for their patients, in much the same way as an attorney is an advocate for his client.”
Unfortunately, those doctors will be on the obamacare hit list and not be able to have hospital privileges.(The you will assimilate clause)
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The common riff-raff like you and I will be screwed.
Eventually to be outlawed for the proles, only the politburo elite will be allowed.
Leave for medical care and IRS will confiscate all your accessible wealth, inaccessible wealth now makes you a criminal.
You can leave but you can never check out.
Medical tourism will become a big business.
I foresee a rise is out of country vacations for surgeries.
Actually, I believe the GOP-controlled House of Representatives has on multiple occasions voted to repeal OdumboCare. Reid and the dems just sit on it in the Senate and, of course, even if the Senate did pass the repeal, the Won would just veto it.
Work on getting good conservatives elected to the Senate next year; donate if there are not races in your state. I think that the scandals currently erupting in Washington, combined with what I expect will be near-universal revulsion with what OdumboCare is going to do to our health care system and health insurance premiums, could easily lead to a electoral tsunami in November 2014. It's even conceivable (though not likely) that we, the good guys, could have an almost veto-proof majority.
Unless, of course, the eGOP once more snatches defeat from the jaws of victory.
Just two tiers? I don’t think so... Many tiers... With healthcare for the poor being at the bottom, the subsidized middle class in the middle, and those able and willing to pay the most being at higher tiers.
It amuses me when otherwise conservative people think that “equality” can and should be mandated for some services that we pay for and consume, while other goods and services should have their prices set by the market. Government intervention strikes again by “we the people” and the puppet masters we elect...
“Sorry sir, but our records indicate that you are a conservative and own a firearm, therefore your daughter is not covered under the current healthcare system. So I regret to inform you that she cannot have the needed medical care she requires and will no doubt expire sometime later today.”
The rich can always afford better. It’s one of the reasons to work hard to be rich.
“Of course, people of means will eventually find a way to pay for better service. There are already the beginnings of medical tourism for elective surgery. My crystal ball says that offshore medical clinic ships will become a reality. Medical care on those ships will be like gambling on a cruise ship, where the slots are turned on and the wheel starts to spin once the boat is 12 miles offshore.”
BOL! When Hilliarily/Willy care was being pushed. I made my living calling on Doctors, Hospitals, and clinics.
Several of my customers, and I came up with the concept of concierge medical offices where the docs received a yearly or monthly payment for a person’s outpatient health care. The docs would only accept cash and no insurance. Insurance was to be used for hospitalization and lab costs. The patient would be responsible for the paperwork. Those not wanting to do the paperwork would be referred an independent contract person getting about $50/hour to do the paper work and exceptions approved.
A couple of surgeons contacted me, and we came up with the idea of Surgery Cruises where the surgeons operated 12 miles off shore while their family members came along to take a cruise and be with their family member.
Fortunately, Hilliarily/Willy care was killed.
” Im not surebut one way would be to forbid doctors accepting insurance payments from having any sort of side contract for additional service.”
Our current concierge docs have nothing to do with Medicare or any health insurance you pay $2,000 up front or a monthly fee costing about 10% more. That cost is out of pocket and no one reimburses you.
I’ll never forget these 2 rich husband and wife lawyers my wife and I had dinner with a few years ago..
During dinner, in their lavish mansion in Beverly Hills, they brought up, in a rather condescending manner, how much they felt the “folks” needed Obamacare.. (meaning those at the table of less than desirable income)....tsk tsk dear, we really must take care of the poor... they are so needy..For these two smarmy condescending smirking power players, the poor are a couple like us with less than 125k in yearly income.. Mind you my wife and I work hard, and we enjoy life. We do however have a smaller house and less disposable income. Big fricking deal. And I don’t have any problem with people making tons of dough.. Good for them and god bless them. I just can’t take the condescending attitude that wealthy liberals have. I am reminded of the South Park episode in which one of the fathers is so smug about his new Toyota Prius.
It grates on me to this day...Meanwhile, this kind of healthcare does not in any way affect these rich liberals. If they need any type of healthcare whatsoever, they just pay for it.
Sheesh, I recall growing up in Ohio and when we needed healthcare, a doctor with a black bag showed up at our house. He had his penicillin and other drugs right in his bag. He would bill us and my parents of limited means, would pay him in installments.
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“Amazingly, one in five patients who enters a hospital emergency room leaves without ever seeing a doctor ? presumably because they get tired of waiting.”
Probably illegals, Medicaid, young people buying IPhones/PADs and Macs and not buying health insurance, all seeking free health care. So they weren’t really emergency patients.
We have heard of this Granny back in the Midwest with adult married children with kids on her and her husband’s side of the family. She is the on call granny when one of the grandkids get hurt or sick enough to go to an ER. She wears an ICE hat and jacket into a crowded er waiting room. Usually that clears out about 90+% of the waiting room. If the room is filled with the local white/brown/black trash drug seekers. She will bring her husband, who is a retired sheriff deputy wearing his sheriff’s ball cap and jacket.
Between the two of them, they empty the poseur patients and illegals from the er waiting rooms rapidly.
There will be snap back.
“It amuses me when otherwise conservative people think that equality can and should be mandated for some services that we pay for and consume, while other goods and services should have their prices set by the market. Government intervention strikes again by we the people and the puppet masters we elect...”
It is amazing how many wealthy people, both conservative and liberal feel that they should get the Cadillac health care and not pay for it. Many don’t even want to pay the copay and demand lengthy medial office time to get prior approval for a non formulary drug. Some of the worse are the business owners, who got a bare bones policy for their workers and want extra for themselves.
“Its the communist way, comrade”
No it is not. The communist way is closer to the system we have now.
I will welcome a system where I can pay for the care I wish to receive, and everyone who wants it for “free” has to wait in line.
THAT is the American way. If you don’t pay, wait in line for whatever someone else is willing to pay for you to have care.
” If you really need that surgery, then pay up! “
What is wrong with that?
Secondly, payment of $1000-$2000/year for quality concierge medical care should not be an undue burden for most middle class Medicare recipients. I wager that monies spent on Netflix, cable, smart phones etc exceed this amount. Priorities, priorities.
I expect to be flamed.
“They will outlaw tier 2.”
That is how the Canadian system operates. We don’t want to emulate that. The UK and Australian systems allow for a private side to care, and a substandard “free” side to care.
CMS/Medicare already has regulations that hamper "concierge" medicine. Medicare will only pay for hospital or specialty services when referred by a participating Medicare provider. Thus, if you are of means and want to have your medical care be off of the grid, so to speak, you have to pay cash for all care. The answer may be the development of concierge hospitals that do a cash only business. Even that may be problematic as licensure of hospitals is tied into compliance with CMS/Medicare regs. As point out, tier 2 can be simply outlawed.
What is wrong with that?
The article misses the point. There won't be two tiers. There will be one crappy level of service mandated by law for everybody.
“I expect to be flamed. “
There is still quite a bit of socialism in many so-called conservatives.
They will be cured of that malady waiting in line for medical care that they will not be satisfied with.
Isn’t this happening now? There are those on Medicaid and those who have health care that they pay for or partially pay for with their employers.
“The article misses the point. There won’t be two tiers. There will be one crappy level of service mandated by law for everybody.”
I agree that will be the preferred method for bureaucrats, but they will not be able to suppress a second tier. Even if out-of-country, or black market - it will be available.
Yes, and then those same business owners who selected lower cost, higher deductible health plans scream about how high their deductibles are.
However, one must also admit that a lack of meaningful consumer price competition in USA healthcare has enabled an often wasteful and inefficient and over-price healthcare delivery “system” to develop and become entrenched. But, that, too, is rooted in governmental intervention for many years, causing great cumulative effect. Distortions caused by a “little” govt intervention often lead to an accelerating cycle of greater distortions followed by greater interventions to “fix” the problems while actually making them worse..., and so on. Sooner or later it breaks down unless it can be overhauled.
Concierge medical care may be a good choice for those who can afford it.
Several of our younger relatives and friends , with good jobs and incomes are looking at going to Concierge medical care to avoid hours in a doctor’s waiting room with the unwashed, illegal, gang bangers and others even lower in the Gene pool. Apparently, some conservative talk show hosts have said this is a good idea.
With any choice, use Buyer’s Beware. It might be best to try a few months versus paying for a for year. Two couples who opted for Concierge medical care had the opposite results. One couple found it harder to make appointments with their Concierge doctor than their old doc who had reduced his office time to two days a week. Their Concierge doctor never returned call and didn’t follow through. Fortunately, they had opted for the quarterly payment and left after a few weeks. It wasn’t a non refundable yearly payment.
The other couple love their new their Concierge doctors, staff and NFP for the docs, they still see their Concierge docs, and will renew their annual contracts.
Another possible option for basically healthy young people is to approach the Concierge doctors and offer them $150 cash for the setup visit and a $100/visit afterwards. We know healthy singles and couples who have been successful with this up front deal. They seldom need to see a doctor more than a few times a year.
I agree that will be the preferred method for bureaucrats, but they will not be able to suppress a second tier. Even if out-of-country, or black market - it will be available.
They can suppress a second tier with laws. A so-called second tier participant will become an outlaw.
Hillarycare would have banned private payments to doctors.
I think under Obamacare, somewhat affordable care will be available for those willing and able to travel outside the USA.
For a few years I was a volunteer working with indigent people, many with various disabilities. I noticed when many of these people were enrolled in Medicaid they would go to the doctor frequently. They would go to the doctor if they caught a cold. In two different cases I remember clients called ambulances because of perceived “heart palpitations.” In neither case could the EM doctor find any problems after doing a range of tests.
If you advertise “FREE” kittens or puppies the people who show up at your door are mostly those too dysfunctional or poor to take care of a pet.
Nothing, if the cost reflects the service, and isn't a huge payment for five other people who don't pay through government mandated cost-shifting.
“governmental intervention” is the great cost increaser and inhibitor for any business.
We are in the midst of refing our mortgage. We have been with the same bank for 20 years. We have a checking acct, two saving accts, a line of credit, a debit card, safety deposit box and other stuff with them.
Our credit ratings are over 800, and the bank gets direct deposits from our IRAS, SS, my pension and other income generating sources. So the bank knows exactly how much per month net income we have each month and will have.
We have lived in the same home since the 1970’s and the Zillow appraisal shows our home and neighbors’s homes to be valued above the great Pelosi/Reid/Barney lite in the loafers housing crash.
In spite of our documented stability and great credit rating, since, we are considered evil white people by the current administration, we have to have a ton of stuff besides the obvious hard data above for our approval.
The lady in charge of our loan process, said the cause is the raft of people they had to hire to meet fed/state regulations working out of some isolated office, who make everything a hassle. She said 8 years ago, we would have been approved in a couple of days with a drive by appraisal.
Welcome to Europe.... Public vs Private.
Not sure. But I am certain in which one members of Congress and the Executive Branch will be.
When that happens, it is time to start shooting the “other tier”.
Its already started... see “concierge” medical services. Every day more doctors are signing up to be included in these programs.
I’ll predict there will be American clinics that treat only Canadians, and Canadian clinics that treat only Americans. The airlines will be the big beneficiaries of Obamacare.
That will be the time to assure that IRS clerks leaving work have "accidents".
Why would the government want to keep you from doing something that would reduce the load on the medical system and cost them nothing?
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