new insurance ?experiment?

[16th ave.]

it sounds good on paper. but will it work? any thoughts on this, anyone?

Cutting Health Care Costs by Putting Doctors on a Budget - Yahoo! News

What if you went to your doctor suffering from congestive heart failure, and your doctor had been given a limited budget from your insurance company to treat you? If he were to go over cost, he would pay out of his own pocket. If he spent less than the allotment - and you were satisfied with your treatment - he would keep some of the change.
This is the guiding principle of a pilot payment model called Prometheus, which, by January 2010, will be used to calculate insurance coverage for 80,000 workers in Rockford, Ill., and has already caught the eye of the White House. Why? Because it turns the current insurance reimbursement system on its ear. See the top 10 medical breakthroughs of 2008.
A major problem with American health care today is what policy experts call "perverse incentives." Doctors and hospitals bill insurers for every individual service - every office visit, MRI or hour of operating room time - a "fee for service" model that drives health care inflation by rewarding providers who order potentially unnecessary tests, perform potentially unnecessary surgeries and even make mistakes. A hospital re-admission caused by avoidable complications just means more billable expenses.
In contrast, Prometheus, which is funded by a $6 million grant from the Robert Wood Johnson Foundation, calculates compensation for hospitals and doctors based not on the specific treatments a patient receives, but on the care a patient should receive "per episode." (Prometheus's calculation model is an open-source program that is already garnering interest from other insurers in Minnesota, Pennsylvania and elsewhere.)
Taking the congestive heart failure example, here's how the payment scheme would work: A slightly overweight 60-year-old heart failure patient comes in with coronary artery disease and acid reflux disease. According to a Prometheus algorithm, this patient should cost $20,750 a year to treat - including office visits, medications, blood pressure monitoring, and an allowance for complications. The incentive for the heart patient's doctor to spend less than $20,750 is that he gets to keep a portion of the difference (assuming the patient was managed properly and happy with the outcome). And the best way to keep costs low is to offer the best care: If the doctor ua negligent in monitoring the patient's condition or faila to counsel the patient fully about proper diet and exercise, that patient could have a heart attack - requiring more treatments - and the doctor would take a financial hit. "The more defects you prevent, the more money you make," says Francois de Brantes, the health payment reform guru who coordinates Prometheus. "The fact that anybody has a leg amputated for diabetes" - something that's preventable with proper treatment - "is revolting, so you make that a financial blemish."
It's a simple idea and makes sense in theory. And yet, no patient wants to believe his own doctor is this focused on the bottom line. While data indicate that up to 30% of U.S. health care spending is for unneeded and even dangerous treatments, the truth is that most doctors aren't purposefully ordering up tests or treatments just for the cash. "The system is asking them to do what's right for a system that lives off of excess, as opposed to what's right for the patient," says de Brantes. See pictures from an X-Ray studio.
Doctors are quick to say much of the 30% of excess health care spending is on "defensive medicine" - providing extra care in an effort to avoid malpractice liability - but De Brantes counters that the Prometheus model creates budgets based on clinical practice guidelines, which, if followed properly, help protect providers against malpractice claims.
(The Prometheus project is named after the Greek god of forethought, but is also a lengthy acronym for "Provider payment Reform for Outcomes Margins Evidence Transparency Hassle-reduction Excellence Understandability and Sustainability.")
Still, overhauling the current health payment system has other pitfalls. Back in 1983, Medicare initiated a similar plan, bundling payments for hospital stays, but the program acquired the unfortunate label "quicker, but sicker." Since hospitals were paid a certain amount of money for each patient no matter how long they stayed, many patients were discharged sooner than was prudent, which transferred the burden of care onto nursing homes and created a "mini-industry of re-admissions," according to Gail Wilensky, a former head of Medicare. "Redesigning the reimbursement system is not for the faint of heart," says Wilensky. "This is in large part about changing the way doctors behave."
Indeed, doctors have so far managed to avoid such reform in their own practices, and lawmakers may be running full speed into a minefield with any efforts to change their behavior. Physicians will accuse politicians of getting in the way of the doctor-patient relationship; device makers will say a "bundled" fee structure will force providers to use cheap outdated equipment; and hospitals, already strapped for cash, will resist any reform that decreases their reimbursements.
In a recent speech to the American Medical Association, President Barack Obama urged an audience of physicians to get on board with bundled, per-episode care. "You entered this profession to be healers," he said. "Now, that starts with reforming the way we compensate our providers - doctors and hospitals. We need to bundle payments so you aren't paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead paid well for how you treat the overall disease."
With or without physicians' support, the idea may be creeping forward. Last week, De Brantes was part of a group of health payment reformers invited to the White House to explain how "bundling" works. Meanwhile, the federal Centers for Medicare & Medicaid Services recently started a three-year demonstration project that will provide "bundled payments" to hospitals and doctors at five sites for 37 common surgical procedures. The idea is that if hospitals and doctors are paid out of the same pot, they'll coordinate services to be more efficient and cost-effective. The results could help determine how aggressively the federal government will end up pushing the bundled payment model onto the entire Medicare system.
If that happens, health care providers may have to put their money where their mouth is. They talk endlessly about delivering health care more efficiently and providing better preventive care - two essential factors for the reduction of overall health care costs - but providers have been discussing the same factors as long as the idea of health reform has existed. Meanwhile, health-care costs, fueled by the "fee for service" model, are growing some 10% annually. In the end, the only way to get change may be to get real about the fact that, no matter how uncomfortable it makes us, health care and money are inseparable.

[IADad]

Well, my first thought is "Wow, that's a lot to read....LOL!"

It makes sense, BUT, I have a few misgivings up front. First of all the whole supposition that forethought in treatment leads to the most efficient care is not a new idea...remember HMO's, they haven't exactly panned out to be fulfil their promise of a healthier, thus less costly society. This seems like really the same thing, but focused on the primary care physician. So, I like it but I have a hard time believing it will work. My biggest misgiving is that it doesn't satisfy the immediate gratification craving we and our doctors have. The empahsis is on the long term and while that's probably correct, it's not something we're overly patient (no pun intended) about. So, isn't it possible that there could be a certain segment of doctors who neglect care to cash in on their part of the savings and then essentially skip town before all the bad stuff happens?

Second, I'm pretty fuzzy on how this "I'm happy as a patient" thing works...maybe I'm happy with the treatment I've been given but find out 10 years later it was entirely lacking and/or inappropriate. What if I'm not happy? Am i to assume Doc will just keep treating me and trying something different in an attempt to keep me happy, while his or her ROI goes down the tubes, or will he be tempted to dump me on another doctor?

Third, what's the cost of the oversight overhead. Okay, so there's this whole new system, and I see it's open source, but somebody still has to have the governing hand to say this is the expected amount and that's goingg to cost somebody something. then there's the administration, changes in how billing is done, I'm just not so sure this will result in significant savings.

and Fourth, what about access, right now (right or wrong) because institutions can bill for useage, we have things like MRIs, for example. If they are used less which the model would naturally dictate, otherwise where is the savings coming from, then what happens when it's not self sustaining? Does that mean there won't be an MRI in my town when I need one? As inefficinet as our health care delivery system is, the one thing that's pretty hard to argue against, is it has lead to some pretty amazing medical technology being pretty readily available.

The one thing I really do like about the model is that it's not a top down cost control model that would decrease doctor compensation and potentially drive drs out of the feild. Unlike the people the article talks about I'm a pretty firm believer that Drs love what they in part because they are well compensated for it (which, of course, is a generalization.)

[Xero]

I didn't read the whole thing because my attention span is limited right now, but I'm right in the middle as to whether or not this is a good thing based upon what I did read.

One - When given only so much to use, and the more they use the less they get to keep, you know there will be case after case of doctors not doing everything that needs to be done in fear of losing money for themselves. Everyone knows that first priority in this world no matter who you are is "ME". You know?

Two - But then, if we continue to pay doctors for literally everything they feel like doing, they'll keep putting us through uneccessary stuff, which I HATE. Seriously, I can't tell you how many times I've seen a doctor (or experienced a doctor) doing the stupidest stuff that's not needed to be done just because they know that we (or the insurance companies) will have to pay them out the wazoo for it. I actually had a doctor in the ER lie about the condition of my son just so he could put an IV in his arm once, and yes this was confirmed ON PAPER by Eli's pediatrician who came into the picture a couple hours later. I've experienced these things myself as well, and they did the same thing to my BF when he had his car accident. It was insane.

So I think there's no way. Money can corrupt a person, and many doctors turn money hungry when they realize how easily they can get it. They know people assume that they are only doing what they feel is best, and doctor knows best. But don't ask me, I hate doctors.

"The biggest problem with the way that we've been doing things is - the more I give to you the less that I'll be keeping for me." - NIN

[Jeremy+3]

Thats why I like our NHS doctors don't gain from medical treatment, they are paid the same to take a temperature as they are to do minor surgery, so they don't do stupid things that aren't needed as they don't receive any gain from it.
Obviously it does have faults, but so do private systems plus I always know my health will never depend on wealth.

[16th ave.]

even though i posted it, i don't much have an opinion on it. really. except that no one should be able to make money off my health.

and i just wish it was all straight so that it was affordable for everyone.

[Xero]

Jeremy - I totally agree. I would love to have a healthcare system like (ie) Canada. They are doctors because they want to help people, not because they want to make tons of money screwing people over. :/

[IADad]

Originally Posted by 16th ave.

even though i posted it, i don't much have an opinion on it. really. except that no one should be able to make money off my health.

and i just wish it was all straight so that it was affordable for everyone.

I disagree, I want them to be able to make money off treating me, just as I want the grocer to be able to make money selling canteloup, now I don't want them to make money off treating me inappropraitely, just like I don't wan the grocer to sell me a grape and charge me for a canteloup.

and as for Canadia Xero, I've heard an awful lot of people posting on other boards who have had to wait an awful long time for stuff.

[Xero]

Yeah, that's true. I have heard from people that live there as well who complain about the wait to get medical care. :/ I guess its like lose lose wherever you go lol.