werner@aecom.UUCP (Craig Werner) (12/13/84)
In an effort to bring down the high cost of Health care, there has been a spread of HMOs (Health Maintenance Organizations) and reimbursement by DRGs (Diagnostic Related Groups). To oversimplify, these work by Pre-payment by the patient (HMO) or a set fee for the diagnosis (DRG), and replace so-called Fee for Service arrangements. (Pay for each test, pay for each day in the hospital - the more the doctor does, the more he gets paid). With the new system, reimbursement is fixed. So that if a patient requires extra care, the doctor (or Hospital) gets no extra money. So in the extreme, the most money is made by non-treatment of the patient. Incidentally, the argument for the above arrangement is that it discourages Useless tests (most of which are useful in many cases but may be superfluous or done for legal - fear of malpractice suits - reasons) and also encourages the patient to seek more health care - since it's paid for in advance, why not go for regualr checkups, etc. However, can others see the chance of the system's abuse? Especially with the rise of Health Care for Profit chains of Hospitals (i.e. Humana). Post or mail, I'd like to see this discussed. -- Craig Werner !philabs!aecom!werner What do you expect? Watermelons are out of season!
doug@terak.UUCP (Doug Pardee) (12/15/84)
> In an effort to bring down the high cost of Health care, there has > been a spread of HMOs (Health Maintenance Organizations) and reimbursement > by DRGs (Diagnostic Related Groups). What we have here is a very knotty problem. The medical profession (in its widest sense) has produced ever more safe, non-invasive tests and safer treatments, and more thorough diagnostic procedures, all of which can generally be considered to be beneficial to the patient. The chances of complications from tests, side effects from treatments, and results of misdiagnosis and consequent improper treatment are able to be lowered considerably. For a price. I can't answer how much extra I would spend to buy safer, more accurate tests and more sure treatment for myself. I don't know how anyone can presume to decide this issue for me. That includes legislatures, insurers, hospitals and doctors. Sure wish I had an answer... Doug Pardee -- Terak Corp. -- !{hao,ihnp4,decvax}!noao!terak!doug
jmm@ski.UUCP (Joel M. Miller) (12/16/84)
In article <> werner@aecom.UUCP (Craig Werner) writes: > > In an effort to bring down the high cost of Health care, there has >been a spread of HMOs (Health Maintenance Organizations) and reimbursement >by DRGs (Diagnostic Related Groups). > > With the new system, reimbursement is fixed. So that if a patient >requires extra care, the doctor (or Hospital) gets no extra money. > Incidentally, the argument for the above arrangement is that it >discourages Useless tests (most of which are useful in many cases but may >be superfluous or done for legal - fear of malpractice suits. My family & I just switched from conventional health insurance to the Take Care HMO, mainly because the HMO is cheaper. It occurred to me that the payment scheme would encourage under-treatment, but malpractice suits (which encourage over-treatment) are still a factor, and I'm betting that the two influences will cancel, resulting in appropriate treatment.
eric@milo.UUCP (Eric Bergan) (12/17/84)
> > In an effort to bring down the high cost of Health care, there has > been a spread of HMOs (Health Maintenance Organizations) and reimbursement > by DRGs (Diagnostic Related Groups). > To oversimplify, these work by Pre-payment by the patient (HMO) or > a set fee for the diagnosis (DRG), and replace so-called Fee for Service > arrangements. (Pay for each test, pay for each day in the hospital - the > more the doctor does, the more he gets paid). No sane person that I know currently considers DRGs to be good. For one thing, they totally ignore the age of the patient. Taking care of a broken hip for a 10 year old is significantly different thatn taking care of a broken hip for a 70 year old. Also, there are currently gaps in the codes - last I knew there was only a code for out patient cataract surgery, not in patient. But, there is a reason for the attempt. Hospitals are currently rewarded for keeping patients longer than medically necessary, they are paid by the day, not to treat the illness. I am currently involved with an attempt to overhaul a hospital to bring its office practices into the 20th century. There is no attempt made currently to optimize the scheduled tests, or the flow of paper work on the patient. One example that I know of involves the radiology department treating the in patients as sort of a queue, they fill in the times between scheduled out patients with in patient tests. While an in patient is waiting for a radiology test, they can not be scheduled for any other testing. This can lead to one or two extra hospital days per stay. The problem so far does not have any simple solutions. But it is clear that health care can not continue in its current form, it already accounts for a staggering amount of the GNP. What the final, humane form of medical care will be is going to take some trial and error, and there are going to be some inequities during this time. Wish I had the answer. -- eric ...!seismo!umcp-cs!aplvax!milo!eric
abc@brl-tgr.ARPA (Brint Cooper ) (12/22/84)
> My family & I just switched from conventional health insurance > to the Take Care HMO, mainly because the HMO is cheaper. It occurred to > me that the payment scheme would encourage under-treatment, but > malpractice suits (which encourage over-treatment) are still a factor, > and I'm betting that the two influences will cancel, resulting in > appropriate treatment. I, too, find certain advantages in an HMO. However, I suffer from a chronic, presently uncurable neuromuscular disease. If I don't get the correct treatment, I could be totally unproductive, even die. The most competent care for this nearby is at the Johns Hopkins Medical Institutions and a few "outside" neurologists with staff and adjunct faculty priveleges there. I have yet to see an HMO that would allow me to see these people and be treated at Hopkins. Am I wrong? Brint
eric@milo.UUCP (Eric Bergan) (12/23/84)
> I, too, find certain advantages in an HMO. However, I suffer > from a chronic, presently uncurable neuromuscular disease. If I don't > get the correct treatment, I could be totally unproductive, even die. > The most competent care for this nearby is at the Johns Hopkins Medical > Institutions and a few "outside" neurologists with staff and adjunct > faculty priveleges there. I have yet to see an HMO that would allow me > to see these people and be treated at Hopkins. Am I wrong? > While not on the same level of seriousness, my wife required jaw surgery about a year ago to correct some orthodonic problems. Our HMO does not have an oral surgeon capable of handling the procedure, so they allowed us to go to one outside the plan (at Johns Hopkins, as a matter of fact), and still picked up the bill. I won't say it was easy, but after a doctor from the plan examined my wife and determined the surgery was necessary, and not merely cosmetic, they did let us proceed. As insurance, I also made sure I had a written statement from them saying they would cover the operation. But there was not any problem, and the surgery occured without hassles. I don't know if all HMOs are like this, but mine certainly handled it in the way I thought most reasonable. -- eric ...!seismo!umcp-cs!aplvax!milo!eric