There is a natural antagonism between doctor and insurance company which,
for all the grief it causes us, is probably healthy in the long run. You
have the doctor arguing on behalf of the patient, versus the insurance
company which is trying to contain costs. The problem shows up when the
doctor and the insurance company are one and the same.
                                           ____________________________
Ed Uthman, MD                             |Note: Because of my provid-|

Pathologist                               |may not see posted follow- |
Houston/Richmond, TX, USA                 |up messages. Please send e-|
                                          |mail copy if you wish a    |
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--
Mark Vivino                            National Institutes of Health
Biomedical Engineer                    DCRT/CBEL/IPRS, 12A/2033

* training physicians (post graduate and med school)
* medical research

As far as I know, managed care does not do these and probably never will
elect to do so. In essence they would like the benefits of the above but
do not want to pay for them. They want the cake and eating it too. This is
where a great deal of unfairness or perhaps unethicality exists.

--
Mark Vivino                            National Institutes of Health
Biomedical Engineer                    DCRT/CBEL/IPRS, 12A/2033

My posting, as requested, suggested an alternate explanation.  Any long
term insurance (managed care or otherwise) for automobile repairs would be
destroyed by the m{*filter*}hazzard problem.  Since I can wear down my car with
no harm to myself, and then demand that the insurer (managed care or
otherwise) pay for repair.  And importantly, for some price, a car can
always be reparied.

The m{*filter*}hazzard problem is not quite so extreme for the health
insurance market.  If I drink and smoke, my health care costs will rise,
and yes I won't have to pay for them, but I will still tend to die
earlier.  So, under insurance I still face some of the costs of my actions.

: You make some good points, but managaed care probably wouldn't have become
: so popular had Medicine been able to keep the public happy. Any serious

I hate to be the one to point this out, but NOTHING can make the
public happy.  The American public is, on the whole, incredibly
ignorant, but likes to base VERY strong opinions on this ignorance.
It is for this reason that we had, here in Oregon, a ballot bill a few
years back which called for the building of god-knows-how-many new
prison facilities, but did not provide ANY MEANS WHATSOEVER for funding
them.  When taxes go up to pay for it, do you think the people who
voted for it will say "oh, yeah, I voted for that."  NOPE, they'll
say "Hey, it's those damn liberals again, raising my taxes."

Damn near every person in this country thinks that the government
needs to tax LESS and spend MORE on their programs, but less on
everybody else's programs.  Personally, I think we ought to have
universal, single-payer healthcare, but I also think that we'd
absolutely HAVE to raise taxes to do it.  Sure, there are places
that we can cut costs, but medicine is expensive, period.

Put it this way: I saw a cartoon once that had two pictures of
doctors; the one on the left said "Doctor's office, circa 1800's"
and had a professional looking doctor with x-rays on the walls
and degrees and books.  The one on the right said "Doctor's office,
1995" and showed a doctor punching on an adding machine, and the
degrees and xrays were replaced by VISA/MASTERCARD signs.  This is
the way people see doctors today; personally, I would have liked
to see a similar cartoon, but instead it would have on the left:
"Patients, circa 1800," and in that frame would be a bunch of
graves and a couple patients without limbs.  Then on the right
it would say "Patients, 1995" and would have pictures of healthy,
whole, living people.

The fact is, 100 years ago doctors couldn't cure people, they just
made them comfortable while they died (or at least they tried).
If you want to pay the price of a doctor 100 years ago, you get
service for 100 years ago; you die.

In the last three years, I've had almost $50,000 in medical bills,
after being hit by a car on my bicycle.  Fortunately, it was
covered by insurance (mostly).  But even if I had to pay the bill
myself, I'd rather work it off at a shitty job than go without
my leg, which is what I would have done 100 years ago.  In fact,
even 20 years ago, and probably 10, the rod they put in my leg
wasn't available.

Bottom line:  you get what you pay for.  There are always exceptions,
and there are always places where you can say "that shouldn't have
cost so much" (and you may well be right), but if you want good,
universal health care, you gotta pay through the nose for it.

As for the American Public being happy... Forget it; people who
expect something for nothing will always be disappointed.

                        -- David

--
David Weingarten
---------------------------------------------------------
Disclaimer:  My opinion is just that, so don't have a cow.
Political correctness is for weenies.
---------------------------------------------------------

"Philosophy is a game with objectives and no rules.  
Mathematics is a game with rules and no objectives."

If you're going to do that, why not implement single-payer and
be done with it?

Steve

The point that I have been trying to make is that good HMO's that provide
quality care that patients value, and avoid paying for care that does not
improve outcomes,  will *eventually* be rewarded by the consumers
(possibly via their employer purchasers).  Bad HMO's that deny proper
care or pay for excess care that doesn't improve outcomes, will
eventually be punished severely by the marketplace and by the tort
system.  

So in the short run HMO's have a lot of control over the care that we
recieve, but in this rather competive marketplace, in the long run they have
very little control.
--
 Chris Colby              |"If its any consolation, Apu, I've found that

 UW Dept. of Economics    |you just wish Flanders was dead." -Homer Simpson

BTW insurance companies and HMO's are regulated, primarily at the state
level.  In some high regulation states, the state insurance liscense deal
worth a huge amount of money.

A better example might be the much-maligned auto-repair shop.  They
aren't subject to stringent state regulations, but in the absence of
government meddling, rather a lot do provide honest service, and several
private sector ratings organiztions have sprung up (AAA is one that I can
think of off the top of my head).

Another example is climbing gear, absoluty zero regulation, I don't even
know what country my harness was designed in or manufactured.  I do know
that if a number of Petzl harnesses broke during falls, people would stop
buying them in a hurry (and of course Petzl would be sued for damages).

To use the airline example, would you feel safer if one monoply airline
ran every flight, with no incentives for safety, comfort, new innovations,
ontime performance...  

Name a govenment monopoly that provides good service to its customers;
The USPS? IRS? DMV?  Its not that the people working for these agencies
are incompetent, there is simply no incentive for any of them, and
espically their managers to do a good job.      

No, I don't want the government running the hospitals.  The last time I
said this to anyone, they said: "But don't they do a pretty good job
running Federal Express?"  Then: "Dr. Harris, are you okay?  Dr.
Harris...?"

                                         Steve Harris, M.D.

In Australia we have managed to cap our health care spending at about 8% of GDP
as opposed to the USA's 13 % +. Yet the standards of care are on most
indicators equal or better, especially over the population as a whole, and our
satisfaction levels are high.

We practice a less leagally defensive health care style although our duty of
care is present and legally enforceable. It's just that our courts are far more
willing to throw rubbish cases out. "Death by Misadventure" is a real outcome.
IF everyone did the best possible for the patient then you should not punish
people if the outcome is not wonderful.

Secondly we have public health care, in that a goverment funded program pays
the majority of patients costs, although private hospitals and private practice
and insurance, is available and used by about 30% of population. Also our
public hospitals are where all our major research and teaching posts are and
thus we have excellent staff and facilities. No marble foyers but good tools
and people who KNOW how to use them.

Unfortunately in my home state our Conservative goverment is trying to make us
more American by forcing the public system to collapse they believe the US
"private enterprise" model is better, but this is being fought by the federal
goverment and is not mirrored in other states.

Basically healthcare is not a business, it is a public service, it needs to be
efficient, accountable and reliable. There can be a mix of private and public,
but PROFIT is not a determinant of success.

It is of note that our aboriginal population {approx 250,000} has abysmal
health status despite massive spending and this appears to be related to some
sort of cultural status issues, and control and approriateness of institutions.
So the Aussie system ain't perfect, but it seems better than the profit from
the sick and sue em blind alternatives.

Comment: well, Einstein, the same seems to be true of Native Americans
and African Americans in the U.S.  Subtract them out, and our indexes
of health care effectiveness (infant mortality, life expectancy, etc)
beat you all hollow down under.  But I'm sure you'd never be willing to
admit that not all social issues relating to health are medical issues.
 At least, not when it comes to U.S. problems.

                                         Steve Harris, M.D.