Tuesday, October 02, 2012

What Makes for Better Care: Capitation or Fee-For-Service?

In the United States, most medical is rendered on a fee-for-service basis.  The more often you come in, the more money I make (at least from you).  In theory, it motivates doctors to recommend more services, and it motivates insurance companies to bargain for very low payments and to deny services.  Another form of payment is what the HMO's do -- a population is defined and a medical system is given a certain amount of money is divided to provide treatment for those patients.  This form of reimbursement gives doctors the ability to divide the money pot in such a way that the neediest get the most, but it also encourages doctors to offer less care to any given patient.  In such a system, doctors are generally rewarded if there is money left over and penalized if they go over the budget.  Incentives may be put in place to encourage good outcomes.

Mental health treatments are often different from other forms of care in that the medications can be very expensive (okay, there are other expensive medicines that run circles around us, but as frequently-used meds go, Cymbalta and Abilify are money drains) and psychotherapy is a time intensive treatment where there are no absolute standards that determine who comes twice a week versus who comes twice a year.  Capitated systems don't typically (?ever) pay for psychotherapy by a psychiatrist  -- the kind of work I do -- and they don't typically allow for on-going weekly psychotherapy sessions, unless it's felt this is absolutely necessary to prevent a more costly hospitalization.

What system are you covered under?  What do you think works best and why?  Obviously, I interested in hearing from our readers outside the United States.    


Anonymous said...

Well, when I lacked insurance and sought mental health care, I very quickly lost a great deal of money and fared worse than where I began. Even if I had been employed like I used to (single person with higher than median national income), I still would have been in the red for the cost of treatment. So I believe that pay-for-service mental health is really only possible for folks with excellent insurance or atypically wealthy.

I am all for outcomes-based payment. If individuals/patients are the primary payers, than I believe that they should negotiate upfront the amount of money they will spend for the outcomes they hope to experience. If possible they should pay upfront, or with a graduated payment plan. If outcomes are not achieved, patient and doctor can decide together whether to refund the patient or continue working together (without further payment if the desired outcomes are unchanged) until the outcomes are achieved. If providers are confident in their ability predict liklihood and extent of outcomes over a population, than they should be able to price accordingly, taking into account that they may be providing services for no cost if clients do not improve.

If government/insurance pays, they should be able to help price services with their own population outcome data. Government-paid doctors should get paid more if their patients do well, and less if they don't. HMOs as you already describe already kind of do this in their networks.

Ideally, such systems should force folks to think through cost-effectiveness, how to approriately divert resources, and how to maxamize outcomes (as outcomes determine pay).

I don't the process of engaging in mental health care should be much different than working with other contracted professionals. If my air conditioner breaks, I can get several repair companies to assess why it borke, how to fix it, how long it will take, and how much it will cost. As a consumer, I can decide who to contract with and negotiate the cost, and hold the repair company liable if they breach contract (just as they can hold me liable if I don't pay when intended outcomes as contracted occur.)

I think mental health professionals need more skin in the game. Mental health care is a huge industry with a lot of waste/harm. If providers are truly confident enough in their treatments to risk pay-for-outcome payment systems, than I think we will have very skilled providers making lots of money and lots of people feeling much greater well-being. If they are not, then at least more folks won't be exposed to the risk inherent in current mental health care and use their money, time, and energy in ways more beneficial for them.

Anonymous said...

I'm covered by the taxpayers of Canada. Due to my lack of income, most services are covered including my medication.

My psychiatrist does not directly cost me money. He's covered by my MSP. My medication is covered by Pharmacare. I'm on one of those money-drain meds, and there's certainly no way I could afford it on my own.

My mother, who does have an income, also receives these same benefits. The only difference between her and myself is (a) she needs insurance to cover the costs of her medication and (b) she has insurance to cover eye care and dental (which I also don't receive as part of MSP). If she lost her job tomorrow though, she could easily call Pharmacare to report a drastic change in her income and immediately have her meds covered by the province.

My therapist, on the other hand, is not covered by MSP and I have to pay out of pocket. Thankfully, we do have the CMHA, who provide support and therapy groups as well as a host of other programs, and each province has additional groups that provide the same for certain populations. We also have our universities and their sliding scale/low-cost therapy, as low as $10/session depending on the university. You do not have to be a student at the university.

My doctors see me as frequently as they feel necessary. My therapist sees me once per week. And if I feel I need to see them sooner or more frequently, I can do so without having to worry about the cost.

Obviously, the cost of these are covered by taxes, so it's not as free as people like to think. I prefer it this way though, as I certainly wouldn't be able to afford healthcare otherwise. I don't have to worry about exorbitant hospital bills, copays, or whether or not my doctor is covered by my insurance. I also don't have to worry about being turned away by a doctor because I'm covered by my province instead of some big insurance company, since all people are covered by that same system and all insurance gives is add-ons in care beyond what the province already supplies. MRI? No biggie. Want blood work? Easy peasy. Covered without insurance.

Not everybody likes our system, there are people who would prefer a two-tiered system so they can get their care faster, and there's court-wars that happen as people try to force the government into providing such a system. However, I think most in our country would agree that "free" healthcare benefits us all and few would want to abolish our system entirely.

And for the mentally ill, it benefits this population a great deal. Sure, therapy may not be covered, but the first-line tools such as meds and doctors and hospital stays are, and this allows even those in poverty to receive adequate help. I've been in hospital five times for various lengths, and not once have I had to worry about a bill I'd never be able to pay. I don't have to worry about how I'm going to pay for the medications that keep me sane. I don't have to juggle limits on how many times I can see my doctors in a year before I'm cut off.

I really don't know how Americans survive under their current system. I'd be yet another homeless crazy person. Canada's system isn't perfect, it doesn't cover everything, and it's NOT free, but I'd never in a million years give it up for what the USA has.

Alexis said...

I'm currently covered by a PPO in the United States, under a standard fee for service arrangement.

I used to live in the UK and be covered by the NHS, which operates under a capitation system for GPs. Mental health is definitely one of the weaker parts of the system. Therapy is patchy, and psychiatrists don't do it on the NHS as far as I am aware--not ongoing therapy anyway. You would have to pay privately for that. Their main job is in assessment, diagnostics, and medication, and good luck seeing one. GPs handle a great deal (ordinary depression, anxiety and so on for sure). GPs have a total drugs budget (I'm not sure how it works in hospital, where specialists work; I'm sure they have a comparable system). So, expensive brand name drugs are not prescribed unless cheaper ones have been tried and failed, or are contraindicated. There is a waiting list for psychotherapy on the NHS and if you do get it, it may be time limited, but it can be paid for privately, I think on the order of £50 a session and up.

My feeling is that I am probably overtreated here and was undertreated there, as the incentives seem to be for GPs to resist referral unless it is very clear that it is needed.

Laura said...

I have a HMO plan - a standard plan for state employees in one of the largest states in the US. It has no bells and whistles. No, the plan does not pay for out of network mental health outright. But, I pay out of pocket, for my psychiatrist-who-does-psychotherapy-twice-a-week and submit bills. I am reimbursed 90% after an annual $200 dedubtible - after the first month of the year, the difference is not that much greater then a copay. The reimbursement checks come reliably within 3 weeks of submitting the form.

Under previous HMO and PPO plans I have been reimbursed at 75% and 80% for a psychiatrist-who-does-therapy. Insurances - HMOs and PPOs - actually reimburse at a higher rate for psychiatrists doing therapy then for psychologists or social workers. That is because the code for medication management + therapy reimburses higher then for just therapy. Though it is certainly not as convenient as my insurance paying my psychiatrist-who-does-therapy directly, I am reimbursed essentially the full amount. I would encourage your patients to explore this out of network reimbursement option: if you are not aware of it, perhaps they are not, either.

Anonymous said...

We have Blue Cross and unfortunately have a $5,000 deductible. So my weekly therapy with a psychiatrist gets expensive. We are in a situation where now we can afford it, but I do feel guilty putting so much money towards my "mental health". I did switch from Cymbalta to Zoloft so my meds would be cheaper, but now my physical pain is bothering me again. It seems to be one big trade off. However I am very thankful to have a good therapist who is extremely helpful.

rob lindeman said...

With respect, Dinah, most physicians do NOT charge fee-for-service, not to clients anyway. As you know, we send a bill to an insurance company, or to the government, who pays us some fraction of what we charge. The client pays a relatively small fraction of this charge, and increasingly, they pay nothing at all.

If physicians truly DID provide service-for-fee, there may be an incentive to provide as much service as possible, but the amount of money we would make would be limited by the demand of the clients. When the cost to the buyer is minimal, there is no disincentive to buy as much of the service as possible. Higher cost drives down demand. I suspect strongly that I would make far less money in a real fee-for-service arrangement.

People value what the pay for and pay for what they value. I wonder how valuable my general Pediatric services are to parents who do not pay, or pay very little, to see me.

Much of the income that I make is generated in an arrangement in which the families in my practice buy a TON of services that they would probably not buy if they were actually paying for them.

Alison Cummins said...


I live in Canada. If you have ever met a Canadian, you will know that we value our health care very highly. We pay for it in taxes and we see the benefit for ourselves and our fellow-citizens every day.

You sound like a cranky ED doc, required by law to treat everyone who shows up under EMTALA even when there will be no reimbursement, and resentful that your patients aren't grateful for your charity.

Our health care isn't charity. Doctors are not reimbursed differently for treating different patients. And counter to you state, we value our care highly.

I don't know who your patients are that you despise them so much, but something is wrong.

rob lindeman said...

Alison, we disagree on things, but there is no call for cruelty. What happened to the "living room" rule?

I'm grateful to know many Canadians, most of them much more polite than you! I cannot say that all of them value their health care highly. All Canadians? I suspect there are enough Canadians that, as we say about Americans, anything one says about them is true.

Some families who seek my care appreciate my services and some do not. I consider it a professional obligation to treat all of them equitably and fairly.

I decided to respond to your post only because of your suggestion that I despise the children in my practice and their parents. This is not supported, and cannot be supported by anything I have said here at this blog or elsewhere. To say that you are being unkind would be soft-peddling, but I'll leave it at that.

The icon that accompanies your post displays the mouth of a person who appears to be sticking out her tongue. It's hard to say because the image is blurry. I interpret this to mean either that you are simply contemptuous of people with whom disagree or that you are kidding. If so, you're not funny.

Dinah said...

Please stop snipping at each other.

It's possible to say the exact same thing without personal attacks.

Sheila said...

Hello. My first post here, though I've been reading your blog for quite some time.

I am a psychiatric trainee. I work in a public hospital in Hong Kong. We have a public healthcare system supporting 70-80% of the whole healthcare demand. The remaining 20-30% were covered in private healthcare market.

Essentially your topic boils down to one question: "who's incentives makes the most sense". Several parties are involved: Government, insurance, patient, doctor. Governments wanted to cut costs (becoz it's taxpayer's money!) yet stay safe (our Government gets scolded every time a mental patient commits suicide and goes onto the headline), insurance companies wanted to cut costs, patients wanted to feel comfortable (which does not equate a good mental state), some doctors wanted to earn while some also wanted to improve their patient's mental well-being.

Who is making the most sense out of the above?

I was trained to "collaborate the interests of different parties". I was told to make my decisions based on patient's best benefits. I was told not to jeopardize patient's autonomy. I was told to use resources in the most efficient way for the benefit of the common good.

What I was NOT told, was to make decisions purely based on money.
In that sense I oppose allowing insurance companies to dominate healthcare financing. This either makes a doctor to over-treat in order to earn, or makes a doctor to under-treat because the patient has no (or minimal) insurance coverage.

Capitation makes more sense in that it allows a doctor to make an independent decision away from direct financial pressure. We may be pressurized to cut costs, but the pressure is indirect and there is certain freedom in making "expensive" decisions.

Anonymous said...

As a Canadian, I value the service provided by the doctor who sees my children. I do not use the service more than required because I do not like leaving work and having my kids miss school for no good reason. I do pay for medical care through the tax system. I pay enough taxes that not only I and my children, but others who cannot pay taxes, can see a doctor. I value the fact that our doctor's office is filled with patients irrespective of their own ability to pay. Perhaps some Canadians do not value such a system. Perhaps they believe it is better in the United States. Some acquaintances have sought treatment in the US. They paid out of pocket. Cancer, drug trials that were not available here. There was no miracle. The patient died as surely as if the family had not looked outside our system. The wonderful thing about our system is that rich people end up sharing a hospital room with homeless persons. Even private add on insurance does not ensure a private room if there are not any available the day you get admitted.
I have seen some very big shots jump the line but they need to be hockey players of politicians or have their name of the outside of the hospital. Regular people with wads of dough do not get any better or faster treatment.
I have also lived in the US and can say that while I was seen quickly in an ER setting (thanks to my very generous employee benefits package that provided great coverage) I was over treated. The hospital sutured my wound and gave me extra gauze and stuff. When I got the bill, for which company plan reimbursed, I saw the mark up on that drugstore variety gauze.

rob lindeman said...

It isn't true, strictly speaking, that all Canadians pay taxes for the health services they obtain. Rather than argue the issue of paying for services that one does not receive, or receiving services that one does not pay for... See below, from Wikipedia

Ontario levies a payroll tax on employers, the "Employer Health Tax", of 1.95% of payroll. Eligible employers are exempt on the first $400,000 of payroll. This tax was designed to replace revenues lost when health insurance premiums, which were often paid by employers for their employees, were eliminated in 1989.
Quebec levies a similar tax called the "Health Services Fund". For those who are employees, the amount is paid by employers as part of payroll. For those who are not employees such as pensioners and self-employed individuals, the amount is paid by the taxpayer.
Premiums for the Employment Insurance system and the Canada Pension Plan are paid by employees and employers. Premiums for Workers' Compensation are paid by employers. These premiums account for 12% of government revenues. These premiums are not considered to be taxes because they create entitlements for employees to receive payments from the programs, unlike taxes, which are used to fund government activities. The funds collected by the Canada Pension Plan and by the Employment Insurance are in theory separated from the general fund. It should be noted that Unemployment Insurance was renamed to Employment Insurance to reflect the increased scope of the plan from its original intended purpose.
Employment Insurance is unlike private insurance because the individual's yearly income impacts the received benefit. Unlike private insurance, the benefits are treated as taxable earnings and if the individual had a mid to high income for the year, they could have to repay up to the full benefit received.
[edit]Health and Prescription Insurance Tax

Ontario charges a tax on income for the health system. These amounts are collected through the income tax system, and do not determine eligibility for public health care. The Ontario Health Premium is an additional amount charged on an individual's income tax that ranges from $300 for people with $20,000 of taxable income to $900 for high income earners. Individuals with less than $20,000 in taxable income are exempt.
Quebec also requires residents to obtain prescription insurance. When an individual does not have insurance, they must pay an income-derived premium. As these are income related, they are considered to be a tax on income under the law in Canada.
Other provinces, such as British Columbia, charge premiums collected outside of the tax system for the provincial medicare systems. These are usually reduced or eliminated for low-income people.
Alberta does not levy a premium for its provincial medicare.[2]

Alison Cummins said...


We have universal public health care. It is funded through taxes. Some individuals pay more taxes than others. Some taxes are not visible to the individual because they are a payroll tax. Some individuals do not directly fund health care at all.

The point is that the funding of our health care and the receiving of it are not tied to one another. I do not pay more into the health care system when I need more health care; I am not relegated to getting less or no health care if I pay little or nothing into the system, whether that payment is direct or indirect. None of us get charity. (Well, except refugees and illegal immigrants. That makes us mad, but not at the people who are forced to seek charity. At the people who set up the system such that people who need health care are forced to seek charity when it is unnecessary.)

You are a little unbalanced, but you aren’t stupid. You get the point, you’re just being argumentative so that you don’t have to address the point.

You stated that unless people pay directly for what they receive, then they don’t value it. This is patently untrue. (By this logic, adopted children and children conceived with paid assistance would be loved, and all children conceived for free would be abused and neglected.)

rob lindeman said...

No analogy is perfect, but some analogies are more imperfect than others. This one is a howler:

"...[A]dopted children and children conceived with paid assistance would be loved, and all children conceived for free would be abused and neglected"

The difficulty my interlocutors are dealing with is, I believe, a tendency to view health care services as sui generis, comprising a category totally different from any other product or service. Why is this?

Well, you may argue, this has to do with life and health! How can you put these things on the market?

I may have set up a straw man, but this argument is a non-sequitur. Your life and health are not, in fact, dependent on who pays for your health services or how.

Health insurance is not insurance. It is a benefit for some and an entitlement for others. The language we use matters. When we call it "insurance", we train our minds to think of the money as stashed away for a contingency. Even though we know what health XXX actually is, we convince ourselves otherwise. That's a shame.

There are many reasons why health care services are so expensive, but the primary reason is this: That there is a separation between the giver and the receiver of those services. The separation provides incentives for over-testing, over-diagnosis, over-medication, over-referral, and over-hospitalization. If ordinary people "saw" more of the cost of the health services they consume, they would consume less of it.

The evidence suggests that over-treated people do poorly. That is why real fee-for-service care provides better service, in answer to Dinah's question.

Dinah said...

I love having the Hong Kong perspective here. Who would have guessed. Welcome Sheila!

I have to say that while I believe everyone should get good healthcare, the prospect of sharing a room with a homeless person (or anyone else) is not a selling point to me. If I were ever sick enough to need to be in a hospital, a private room would be very high on my list. Bad enough to deal with my own middle-of-the night infirmities and nursing/medical interruptions, but if I'm sick, I don't want to deal with the person next to me with a cough, 2 AM monitors beeping, or rowdy daytime relatives. Call me a snob. But that's not healthcare, that's comfort care, and while I don't think the taxpayer, or even my insurance company owes this to me, I would like the option to pay for it. If you don't like the public schools, you can pay private schools. If you don't like the food at McDonalds, you can go to a 5-star French restaurant. If I had to be in a hospital, I would probably mortgage my children to pay for a private room, and I wouldn't want to be in a system that refuses to allow this.

In community mental health centers where people do not pay for services, the no-show rates are high. The service costs nothing, and wasting the physician's time also costs nothing. I have not found that the patients are otherwise less appreciative of services. Nor have I found that every patient does not keep appointments, some are very good about it.

Rob -- it's still fee-for-service. In Baltimore and the 'burbs, many docs either don't take insurance or charge a yearly fee in addition to insurance compensation. (Some call it a concierge fee, others do not, and the rates vary). The pediatrician now charges a yearly "forms" free of $15/kid. I don't begrudge him this at all, he has to hire staff to fill it out. Though, I was perplexed that when I got confused and sent in $20 by mistake, they had to call and return the money to me and couldn't either credit my account by $5 or buy an ice cream cone. And blessedly, the pediatrician is a Red Sox fan.

On a related note, I had an article in the Boston Globe years ago about my husband's odd reaction to the Red Sox the year after they won the WS (2005, I believe).

Alison Cummins said...


Not sure where the cruelty comes in?

I think that American ED docs are cranky for a reason. I used to read a lot of ED bloggers; they tend to be right-wing and angry (I can name exceptions, I’m just observing a trend). At the time, presumably still, they thought the problem with the health care system was entitlement. People showed up at the ED and demanded (often very unpleasantly) care as if they were entitled to it. The ED docs provided the care, but it was out of their own pockets. Charity. And they were being ordered around and sworn at by drunks and addicts. I actually think it would be difficult to keep one’s cool under these circumstances. EMTALA is famously an unfunded mandate, so the docs’ effort and care is unvalued both by the government and by the patient. Sounds awful. Something’s wrong there. If I make that observation, am I being cruel? The angry right-wing docs blame the “entitled,” foul-mouthed addicts for not being sufficiently grateful, and while I understand where that feeling comes from I don’t think that gratitude fixes the problem.

In Canada, docs are paid for every single patient who walks in the door. With very few exceptions it’s not charity work, it’s their job. Even when the patients are behaving like jerks, the docs’ effort and care is valued by their employer and is compensated. That, to me, sounds like a better run at that particular unhappy dynamic.

When I make an observation that you sound like a cranky ED doc and that something’s wrong, I mean that something’s wrong. I want to know what it really is, because I doubt that “not valuing healthcare” is actually the problem. You’re a pediatrician in something like private practice, so you don’t have the EMTALA unfunded mandate poisoning your relationship with your patients. So... what is it? Something’s wrong. What?

When I tell my beloved that he seems cranky, I’m acknowledging his feelings. He usually responds really well and tells me that yes he is cranky and explains why and then we have a productive discussion. When my beloved tells me I seem cranky, I feel heard and am grateful.

When I tell you that you sound like someone unhappy about being stuck in a bad place, I don’t mean to be cruel, I mean to demonstrate that I am listening. Obviously I fail.

Alison Cummins said...


You asked about my avatar.

It’s a picture taken with a moving camera, of me smiling with lipstick on my teeth. He likes it and used it to represent me when he set up my blog. So now I use it too.

Dinah said...

ED physicians are salaried by the hospital and they get paid regardless of how many or how few drunks curse at them and vomit on them. It's the hospital that gets stiffed.
I don't envy them.

rob lindeman said...

Hi Dinah,

It was 2004 and 2007, much to my chagrin. On a brighter note, congratulations to the O's for beating James Shields and Tampa Bay 1-0 despite striking out 15 times and collecting only two hits. Good ball clubs win close games. There, I said it (though I wouldn't say it about the Red Sox, EVER!)

You can charge for school forms? I do not. Am I being foolish?

The "direct care" model to which you refer is an appealing one, for many reasons, among which is not included that the model is remunerative. It is not. I'm pleased that the model is catching on in Baltimore and environs. I don't believe I could make it work here because more than half the families in my practice are immigrants from Brazil and probably could not afford a retainer. A reasonable fee, on the other hand...

Anonymous said...

"The 10 percent of Canadian families with the lowest incomes will pay an average of
about $487 for public health care insurance in 2012. The 10 percent of Canadian families
who earn an average income of $55,271 will pay an average of $5,285 for public health
care insurance, and the families among the top 10 percent of income
earners in Canada will pay $32,628".

That comes from a 2012 Fraser Inst report that tries to show how Canadians are paying too much for health care.The only reason I bother with numbers from a Conservative think tank is because the notion that we pay 900 bucks and are done, the rest left to employer payroll taxes is absurd. We do pay high taxes, out of which many services, health care only one of them, are paid. I cannot sit here and tease out how much of my income taxes went into the health care pot but it was a lot. Rob is correct that some Canadians do not pay for health care. That is why those of us with means do pay.
Some people hate that and some people think it is fair to share the wealth. Whether money is wasted in either system is another question and I would say of course it is. What public or private program can we dream up that does not take and fail to live up to promises? That said, give me your hungry and your poor and let them have the bed next to me when I am sick.

Jane said...

"more than half the families in my practice are immigrants from Brazil"

Huh. Interesting. In Florida it's Cubans, New York Puerto Ricans, CA Mexicans, and in Maryland it's Brazilians. Learn something new every day...I wonder why there are so many Brazilians...

rob lindeman said...


The Brazilians aren't here because of the lovely weather in Framingham, neither do they care for our lovely beaches.

It's a simple answer, really. The so-called "Brazilian Miracle" you've heard about is a sham. There are no jobs there. If you are a woman over 30 years of age, you are sore out of luck.

rob lindeman said...

Anon who brought an excerpt from the Fraser report: Thanks for that.

To those who argue that "sharing the wealth" is fair, a question: Why is it "fair" for the State to take away your property ($) and give it to someone else?

And don't get me started on progressive taxation: I have never understood how taking more vig from the biggest earners was "fair".

Anonymous said...

Actually, it is highly incorrect to say that we do not all pay for healthcare.

Do you pay GST/HST? If you pay this, which undoubtedly if you've bought anything, you've paid towards healthcare costs.

Do you pay a provincial tax? Not all provinces do, but if you're in a province with such a tax you've paid towards healthcare costs.

All persons pay toward healthcare. Even the homeless man who scrounged enough cans for the cheapest hamburger at McDonalds pays into healthcare.


And let's not forget that Canada spends less per-capita on healthcare than the USA while still providing more public healthcare than its neighbour. Meanwhile the USA spends the highest per-capita for healthcare while only covering some of its citizens.

I may not directly pay for my healthcare, but I certainly do pay for it, even as a "zero-income" individual. And I appreciate it highly. And during the times when I've been working, I've paid taxes without utilizing the healthcare system. I've met few low-income, "non-paying" Canadians who do not appreciate both our healthcare system and the doctors practising within it.

I don't abuse my privilege. I don't get unnecessary tests. I received a CAT scan and MRI when trying to figure out a neurological issue, I received an ECG in the hospital after it was discovered I have the same condition as my dad, I receive annual bloodwork to make sure my crazymeds aren't screwing me over. Not once has something unnecessary been recommended or offered, and most doctors here do everything in their power to only test what's necessary. And I'm only chucked in the hospital when there's no other option. Some of my medications require Special Authority within my province before they can be prescribed, to ensure equally beneficial low-cost alternatives have been tried first.

As I said earlier, Canada's health care system isn't perfect, but at least it cares for everyone.

Anonymous said...

It is true that some do not pay for their health care and that is not an accusation. In is illogical to think of someone who lives in a government funded nursing home and has for most of his or her life as paying for their health care. Perhaps they also receive a monthly disability allowance from which their favorite foods are bought, or a pair of soft socks. That money also came out of the tax system. And yet, it is fair that we who earn more should pay to provide for people who do not have what we have. Anyone can fall on hard times and some of us who are high income earners have lived life on the other side of the tracks and know what it is like to be on the receiving end of something we have not personally paid for. I would hate to live in a dog eat dog world and I never would have survived had it not been for the funds that other people paid to see that I got an education and health care and even welfare when I was a kid.

Anonymous said...

Canada does have it good. They get to benefit from all of the research and development done in the U.S. but don't have to pay for much of it. They should be paying more for meds than they are.

Dinah said...

Jane, Rob is not in Maryland, he has his own state.

Rob, it was 2005, the year after the World Series victory.

Are we watching the debates?

Anonymous said...

You do realize that Canada's not the only country paying less for their drugs, right? To name a few: England, Germany, India... I could go on; most countries actually pay less than the USA. The reason you're aware that us Canadians pay less though is because we're your neighbour. So we'll roll with that.

Being pissed off that Canada doesn't let Big Pharma gouge the consumer is just silly. Your anger should be directed at Big Pharma for taking advantage of Americans. Research has nothing to do with it, Big Pharma's simply using research costs as an excuse to charge you more money and make bigger profits. Pharma still makes a profit off of their deals with Canada, it's simply not the windfall that they get in good old America.

You could say, "but if we did what Canada did then these companies wouldn't continue researching and making new drugs!"

So long as there's any profit to be made, and oh boy do they make a profit, people will continue making drugs.

Research itself is actually a small percentage of their budget - they spend more on marketing and administration than they do on research. Then we could add in 1boringoldman's entire blog right about here and ask ourselves the question of how much of their budgets go to protecting their backsides from lawsuits that they typically end up losing (and which they deserve to lose, but still, ask yourself, how much of their pie chart is related to their legal costs and lawsuit losses?). Let's not forget the near-billion they spend annually on lobbying to prevent Americans from having the same low-cost drugs that Canadians and other countries have.

So really, the rest of the world has it right, our costs are where they should be, and you Americans are being crazy ripped off.

Anonymous said...

Yes, i realize other countries pay less than the U.S. and some of those other countries have also contributed some to medical research. Also, i mention Canada because they are the ones on here criticizing a system they don't know anything about. What has Canada contributed? Not much. They should put their money where their mouths are, they say they value health care? Then they should pay their share of the R and D instead of leaving it to the U.S. if it were the other way around, we would be screwed - because i sure don't see Canada doing much in that area. Maybe, instead of Canadians critizing our system they should say thanks for all they've benefitted from it.

Anonymous said...

i meant "criticizing." Can't spell tonight.

Anonymous said...

My personal experiences with the U.S. health care system: My younger sister was born with a congenital heart defect and had 3 open heart surgeries by the age of 4. The bulk of which was paid by charity care, my parent paid what they could but were not saddled with years of bills that they couldn't pay, what they could not pay was written off. There was a time when I did not have health insurance, and when I was hospitalized I paid what I could which was next to nothng and the rest was written off. I did not become homeless nor did I become saddled with years of debt. My therapist who had already been treating me at a sliding scale, when I became unemployed allowed me to pay what I could when I could - sometimes it was as little as $5. My psychiatrist was very generous and worked with me as well.

Now, I am in a position to give back. The hospital where I work spends thousands each day on indigent care for patients who are undocumented and for patients who are citizens in financial straits as I once was. I am lucky to work with physicians and patients who come from all over the world. I have worked in direct patient care in the U.S. and on multiple clinical trials. I have seen many miracles.

I have seen and experienced a lot of good, and some bad in the U.S. health care system. There are a lot of caring, talented, and incredibly generous physicians (and other health care workers) here. Are there improvements needed, yes, but I am eternally grateful for the excellent care my family and I have received. Only the bad news gets the press.

Sarebear said...

I've received forms in recent years from a particular company that has alot of urgent care centers, hospitals, and clinics around here, for financial assistance. I've not filled those out, BUT . .

Three years ago, they orderd me a pair of MRI's, to see if my hip sockets had developed deep enough (was having bad hip socket pain and when I all of a sudden remembered I'd had casts on my feet as a baby, it was like a lightbulb for them or something).

Well, the doc had told me to go in and get a cortisone shot in each hip, and then a month after that get the MRI's.

I found out, after my first knee surgery, some inklings that the insurance company did not like the way this came down, at all.

Didn't really find out until I was buried in everything right after the second surgery, that the ins. company only paid 40% of the usual and customary because the doc was supposed to order them so the MRI's were done within two weeks of the order.


To the order of $3600 left over that they were billing us for, oops.

We had so many bills (I don't know how we were even paying the ones we were paying) that there was no humanly possible way to pay them anything. We just ignored it for awhile, we were quite occupied with other things. Like PAIN, 24/7, among other things, and other bills and insurance stuff for the two surgeries and the hip shots.

Things started coming to a head a year after the MRI's (i'm never goin in one of those headfirst, feet first was horrendously traumatizing enough for a person of my size) and we appealed the ins. co decision, which appeal was rejected. We appealed to the facility (with some upset calls to the ortho's office because it was THEIR fault we waited so long to get the MRI's; the doc had told us to do that). After months and months of that the facility finally sent us forms to fill out, basically saying effectively we didn't even have an arm or a leg we could sell them. Had to write a cover letter too, that was tough.

They decided for us, wih only $200 for us to pay (by this time we had a little tax return, that this came out of, alhto my husband was out of work and would be for two years, so that $200 gone was still excruciating. Still, got off lightly, considering).

I still feel guilty about having all that written off . . .

I know after my suicide attempt in '96, that the resulting ambulance and ER bills actually tended to make me suicidal when I thought about them. So I didn't; I ignored them, and eventually they went away, I guess. I feel badly about that now, but I was in no shape to deal with anything (and didn't get any mental health help due to or after that, either).

Sarebear said...

Oh, and we didn't have any tax return to give them before the first year was up, as we needed $5000 for the deductible and then the surgery was paid at 100% (not that we had $5k but somehow we got there). We needed the $2k tax return the next year to go for well living while not employed, but when they write off almost all of it, we had to feel grateful about only $200.

Anonymous said...

Canada sure as heck does contribute plentifully to the medical community. Just a few, last few months?





Canada may not contribute much in the way of direct pharma development, but it certainly contributes to the understandings necessary for that drug research to happen, as well as to the understanding on how those drugs affect (and sometimes cause) other illnesses. Canada contributes in many non-pharma ways, and that research is what brings the companies to create the drugs that you say we don't deserve to receive at the price we do. We also certainly do contribute to treatment development, just not the treatments you apparently would like us to.


Before you say Canada doesn't contribute much, you may want to go back and have another look at our contributions - past, present, and upcoming. Canada may not be the top research country, but we certainly do contribute.

Anonymous said...

What percentage of drugs Canadians take were created in Canada?

Doesn't make a lot of sense for Canadians to come onto U.S. websites and trash the U.S. health care system, if they've never experienced U.S. healthcare nor worked in the U.S. healthcare system, but enjoy benefitting from it. It would be like me hanging out on Canadian health care websites and smugly telling them all that's wrong with their health care system even though I haven't been treated or worked in it. It doesn't make much sense.

Anonymous said...

Let's reverse that: what percentage of drugs do Americans take that were created by European companies? Have you checked out how many of your drugs are from Europe versus America lately?

Yet you still pay buttloads more than those in the country it was created in, where it was created makes no difference. While America spits out drugs left and right, you still pay more for your drugs than necessary, and other countries paying more for their drugs wouldn't lower the cost of your drugs, it would simply increase the profits that Big Pharma rings in. So, despite all your strides in research, how exactly are you benefiting aside from drugs that everyone else gets to pay less for? Oh that's right, we don't question Big Pharma, they're our saving grace, we point the fingers at everyone and everything else.

Where the drug was made has nothing to do with the price that you pay. And none of it would be possible without the research that lead to the discovery that made it possible for drugs to target the illness - research that Canada is a part of. Canada may not be a leader when it comes to drug production, but we're as innovative as the next and the research we spit out has made it possible for your drug companies to make the drugs they profit from.

Should Canada try to develop more drugs themselves? Of course, always. (aside: some of those companies outside of Canada have labs developing drugs within Canada. The country may hail from Europe, or the USA, but that doesn't necessarily mean the drug was invented there)

You're still ignoring the fact that pharmaceutical companies, in and outside the USA, are ripping your country off. Because you make it possible. You don't need to let the company rip you off in the name of drug research, Europe is a prime example of that.

Having said all that, while I may criticize the US healthcare system, I also heavily criticize my own. I believe that being honest about the flaws in our system will help to improve the system in the long run. R&D is the least of our issues:

1. Surgical wait times
2. Family doctor shortage
3. Quebec is a mess
4. Eyecare coverage

So don't think that I'm criticizing the USA any differently than I would criticize my own country's healthcare system, or any other country's healthcare system for that matter. Likewise, you're just as free to criticize Canada as you see fit, it certainly doesn't do our system any harm to receive reality checks from outside sources.

Alison Cummins said...

For Anonymous who thinks that Canadians shouldn’t express horror at the American health care payment mess even though we know about it because of all the Americans express horror at it.

Jen Gunter MD is a Canadian trained in Canada, practicing in the US, so she would know. And this is what she says.


(Parenthetically, she thinks that the medical board exams in her specialty in the US are much easier than those in Canada — much too easy. http://drjengunter.wordpress.com/2012/07/05/why-i-disagree-with-the-ama-over-the-need-for-physicians-to-be-board-certified/ )

Alison Cummins said...

For Rob who thinks that the only reason a human being will value anything is if they have paid cash for it, and that if we think he means kids we’re being absurd.

Exactly. Your point that human beings value things for many other reasons than having paid cash for them is well-taken.

You think the children analogy is far-fetched, but I have heard exactly that sentiment expressed with regard to pets. Breeders of expensive animals state that the reason for the high rate of pet abandonment where I live in Montreal is that people get their pets from the neighbour whose dog had a litter, or they adopt a feral kitten from the alley in the fall. Because the animals were free or low-cost, they do not value them and abandon them easily. As a pet owner, I can tell you that logic is as absurd to me as the same logic applied to children is to a parent.

To a certain extent, I might value things less if I pay for them. The money removes any social aspect of the exchange. I paid for it, therefore I have the right to do anything I want with it, including throw it away. I paid for it, and if what I got wasn’t to my taste then I complain.

If the society as a whole has collaborated to make something available to me to enhance my ability to participate in and contribute to society, like education or health care, then it’s not just about my personal taste. It’s about social engagement. If my doctor expresses concern about me, it’s not because I’m paying her to, it’s because I am a valuable human being.

I valued my mother’s advice, but not because I paid for it.

rob lindeman said...

The ideological battle between Statism/Collectivism and Freedom/Libertarianism is old and probably won't be resolved in the comments section of Shrink Rap, but wouldn't it be really cool if it were?

Suffice it to say that Statism/Collectivism has had its day, and has proven to be a recipe for a solitary, poor, nasty, brutish, and short life for the poor individual.

Although I follow Jen Gunther and respect her highly, I would commend the works of Ludwig von Mises to readers of Shrink Rap. I'm inclined to recommend by John Locke, but unless you're a 17th century Scotsman it's rough reading.

I've read The Communist Manifesto and almost died half-way through Das Kapital. I'd say von Mises and Locke get it right and Marx got it wrong. But we may disagree.

SarahJayne said...

I have a PPO with a $15 copay and $500 deductible. For general mental health counselling there is a limit of 24 sessions in a year. However, if your mental illness is considered "biological" like bipolar or schizophrenia then then there is no limit to appointments. I am bipolar and was tapered off my meds last fall to try to get pregnant. I did well for about 6 months but then crashed into the worst depression of my life. My shrink (an awesome guy) basically negotiated with me that he wouldn't put me in the hospital if I agreed to see him daily until I was stable again. That helped me immeasurably and I saw him daily for 6 weeks. If my insurance had run out and not covered my appointments then I probably wouldn't be here today.

Anonymous said...

I have phenomenol insurance... employment through a government agency - group plan. I pay just $10 per office visit, no deductible and no limit on office visits. This is not the norm I realize, and I also took the job and a munch, much lower salary, because the benefits were so good. I feel very fortunate. There is something to say about coverage. There have been times that I have paid COBRA and some crazy premiums, but it was worth it to me. I have seen many family and friends that have become buried deep in medical debt, or it bankrupt them.

On a side note, it's Mental Illness/ health Awareness Week!

Anonymous said...

I'm curious if psychiatrists who do psychotherapy charge the same rate for psychotherapy as they do for psychiatric services?

Anonymous said...

Mine charges $140.00 for a 20 minute med check, but charges $180.00 for a 50 minute session for psychotherapy. Go figure!

Anonymous said...

Last anon - because med checks are expected to be less frequent while psychotherapy is expected to be more frequent and consistent. Mine charges $350 for either, but doesn't do pure medication maintenance. His minimum is 1 x month, and that session is 45 minutes like any other.

Anonymous said...

Alison, I don't place much stock in the opinions of our health care system when it comes from those who haven't experienced it as a patient nor worked in the U.S. health care system, because you there's a whole lot you don't know.

I have been a patient in the U.S. health care system, I've worked in the U.S. health care system, and I have worked on multiple clinical trials involving other countries. I've even worked with Canadians in U.S. hospitals who have a much more balanced view of our health care system - both the good and bad, and their opinion does mean something because they actually do know what goes on here.

Alison Cummins said...

Are you saying that you don't place much stock in the opinions of Dr Jen Gunter, who works in the US?

Anonymous said...

Nope, i'm not talking about Gunter. i'm talking about people on here who criticize a system they know nothing about.

Alison Cummins said...

Oh Rob, you do like changing the subject.

You stated that people only value what they have paid for. I dispute this statement and find it personally offensive. I offer counterexamples, including some that relate to healthcare.

Alison Cummins said...

Anonymous who is not talking about Gunter,


Anonymous said...

Hi Anonymous whose doctor charges $140 for a med check and $180 for a therapy hour.

I wanted to tell you why the time is not proportionally charged. It takes more work to look after someone who comes in for med checks than for someone who comes in, usually, more frequently for psychotherapy and medication for a longer session.

The longer the time between appointments, the more likely the patient will reschedule, run out of their medication between appointments, have questions arise that they want discussed quickly over the phone. All this easily amounts to the work involved for one or two additional sessions.

Think of the steps: take the phone message, pull the chart, review the chart, return the call, play a little phone tag, talk to the patient, make a plan, call in a script - which alone takes 15 minutes typically, and document it all so you remember what you did at the next appointment, and you probably should charge more for the shorter less frequent appointment now that I think about it.

Some doctors do charge exactly proportionally based on time spent in the office with the patient, but it is less common in my neck of the woods.

I actually have transitioned over the last 2-3 years to seeing almost everyone for 45 minutes. It simplifies everything except my schedule. Now I book up more quickly but I am happier with my patient relationships and outcomes.

Anonymous said...

Hi, I'm the anonymous who asked about charging for psychiatry/psychotherapy. I would expect psychiatrists to charge more for things that require specialist medical training, but it wouldn't seem cost efficient to be charged. I work for the NHS in the UK as a psychotherapist in a multi-disciplinary child and adolescent team, but I trained first as a clinical psychologist. Our psychiatrists are the top of the pay scale and they do things that require their expertise - medication, oversee physical assessment and monitoring, high risk assessment, specialist diagnosis, and case consultation. In my team, at least, they don't do therapy or routine diagnosis which can be done by other skilled professionals. If something is outside of our expertise, then we consult, and they may see the patient themselves. And then they hand them back to their colleagues. It is one of the reasons I like working in the NHS, it means I can safely work with higher risk cases than I would feel comfortable with as a single practitioner and it means care is coordinated and best practice can be followed (e.g., rarely do young people get meds without psychological therapy). In order for us to successfully treat as many people as possible within our budget we have to reserve the psychiatrists for cases that require their expertise.

Anonymous said...

oops! Sorry for the wonky grammar, I didn't review my post carefully enough!

rob lindeman said...

Read the posts. The word ONLY never appears. One sees what one wants to see, right Dinah?

Alison Cummins said...

Rob: “People value what the pay for and pay for what they value. I wonder how valuable my general Pediatric services are to parents who do not pay, or pay very little, to see me.”

You’re right, you don’t say “only.” There are different ways of reading that statement.

1) “People value what they pay for...” I may value something less if I pay for it. I’m not normal, but I exist. This is also what people say when they’re claiming that people abandon their pets because they are too inexpensive and that the problem of abandoned pets would disappear if everyone bought high-priced animals from breeders. I dispute this assertion.

2) “... and pay for what they value.” Sometimes. Sometimes they can’t pay even when they value something very much. Sometimes they prefer to steal even when they can pay. Sometimes they prefer it to be a gift. (Sexual contact and comfort is something many people value very highly, but it’s common to refuse to pay for it.)

3) “I wonder how valuable my general Pediatric services are to parents who do not pay, or pay very little, to see me.” Perhaps you are simply saying that money is the only way you personally have of measuring your value to others? You would need to not only charge a fee, but also look at their tax returns, which would be very intrusive. A person who doesn’t pay for orthopedic surgery for their child doesn’t necessarily not value the care to their child, they may be unable to pay. Someone else might enjoy flashing their money around and buying lots of goods and services to impress other people, not because they value the goods and services. You would have to charge an awful lot of money to those people to determine that they actually valued what you were charging for.

I actually have some sympathy for your statement, “the families in my practice buy a TON of services that they would probably not buy if they were actually paying for them.” More next.

Alison Cummins said...

Rob: “the families in my practice buy a TON of services that they would probably not buy if they were actually paying for them.”

Yes, this is the pernicious aspect of being paid for goods and services: conflict of interest. I see it when I compare my attitude towards medical care (covered by public insurance) with dental care (covered by a mix of private insurance and cash).

I don’t pay directly for my medical care. If a doctor thinks I need a service that is covered by public insurance, I believe them. There are waits for these services, and quotas. The doctor is much more aware of the constraints on the system than I am and has judged that I should get the service. So I do. I trust that the doctor isn’t loading me up with extra tests or interventions. If the doctor tells me I need it, then I must really need it.

(I am completely aware of the pernicious aspects of quotas! Not arguing for them, just reviewing the social effects of a sense of stewardship of a limited resource. I am not arguing for any particular way limits should come into being!)

When I go to the dentist, I am perfectly aware that the guy I see loves dentistry, loves gadgets and technology, wants to share what he loves and has lots of bills to pay. If he recommends something, it may or may not be the best choice for me but I don’t necessarily have the expertise to make that judgement. So if my insurance covers it, I get it. Because I pay for my insurance I feel entitled to get all the goodies it covers; I don’t worry about stewardship. Alternatively, if it’s not covered by insurance I don’t have a good way of evaluating whether I really should buy what he’s selling. He urged a friend of mine to get four teeth capped instead of the two that actually needed capping so that they would all be the same colour. He insisted that she would be unhappy if she only got the two done. Well, she was paying out of pocket and only got the two. I can’t see the difference. She looks fine. She’s satisfied. If it had been me, I’d probably have given in and gotten the extra caps I didn’t need, and given up other things I value more than an imperceptible difference in tooth colour. So far I haven’t been placed in that position — everything he sells me is covered by private insurance, so I have always bought it — but as I age and wear out it’s only a matter of time.

(Clearly I still see this guy. The fact that dentistry is not covered by public insurance does not cause me to boycott dentists.)

rob lindeman said...

"...[T]his is the pernicious aspect of being paid for goods and services: conflict of interest"

This is backwards. Where a service is free or nearly free, there is no disincentive for me, the seller, to sell as much of my services as possible. This is a serious conflict of interest. I fight the impulse every day.

If, however, families had to pay for the services I provide, the disincentive to over-charge and over-sell would obviate my need to fight the impulse to over-treat.

The crux of the problem with capitation, to return to Dinah's original post, is that the burden of making economic decisions falls to the wrong party, namely the seller.

Regarding my dental colleagues:

If you think over-treatment is bad in medicine, it is absolutely B**-S*** crazy in dentistry.

People defer to doctors and dentists too much. That's understandable, if misguided. If people had to pay for the services they receive, they would buy much more judiciously, AND doctors would be compelled to speak honestly about benefits and harms.

Alison Cummins said...

Rob: “If you think over-treatment is bad in medicine, it is absolutely B**-S*** crazy in dentistry.” Yep. And it’s pretty much completely free enterprise. So it’s hard to see how more free enterprise would fix overtreatment in other disciplines.

Rob: “People defer to doctors and dentists too much. That's understandable, if misguided.” Can you be more explicit about the misguided bit? I’ve never had my teeth capped. I’ve only ever seen one person with multiple myeloma, and based on this anecdote I will refuse treatment for it if I ever develop it. I’m really not sure how I’m supposed to not defer to doctors and dentists if I need care for something I’ve never had before.

From reading blogs, one of the things medical personnel apparently hate the most in the world is resucitating someone who is dying. The person is demented and very ill. They go into heart failure. While the medical team leaps into action, a doctor discusses alternatives with the family. Tearfully they say, “Do everything!” Feeling terrible about it, the medical team do everything. Unless the family are allowed to actually watch the medical team breaking granny’s ribs and shoving tubes into her, in which case they tell the team to stop.

So. You are the doctor and you have carefully explained the risks and benefits of attempting to resucitate my dear one and I make a decision. When I actually see you in action, I make a different decision. It seems that your experience of providing medical care gives you a deeper understanding than you can convey by simply listing risks and benefits. *What is so misguided about deferring to someone who knows what they are talking about?* How exactly would discussing a bill to be paid out-of-pocket make this conversation more productive?

Rob: “If people had to pay for the services they receive, they would buy much more judiciously.” As we are both aware, this doesn’t seem to be the case in dentistry. There’s an asymmetry of information problem, a little bit like you don’t know if a particular watch or necklace or whatever is better than that one, you only know it costs more, so you use that as a proxy for “better” and you choose the more expensive one, hoping to get better value. Even though it may not actually be better.

Rob: “If people had to pay for the services they receive ... doctors would be compelled to speak honestly about benefits and harms.” I don’t understand how this follows at all. There is a massive leap in logic here and you’ll need to walk me through it. “If people had to pay for their own used cars, used car sales staff would be compelled to speak honestly about the features and defects of the cars they are selling.” I don’t see how it follows.

Alison Cummins said...

Alison: “This is the pernicious aspect of being paid for goods and services: conflict of interest.”

Rob: “This is backwards. Where a service is free or nearly free, there is no disincentive for me, the seller, to sell as much of my services as possible.”

You’re changing the subject again. I’m talking about the seller getting paid; you’re talking about the buyer paying. These are different aspects of the transaction and can be separated. For instance, you could be paid a lot of money by public insurance to which I contribute little or nothing. Alternatively, you could be receiving a salary for some aspect of my care while I am in hospital and paying out of my pocket and through the nose.

Anonymous said...

Hi Tigermom, you must be a very compassionate therapist to do 45 minutes with each client. Thank you for your explanation.