Thanks.

Maybe a compromise approach would be for the insurance company to cover a certain number of routine doctor's visit (maybe 2 per year), but then have a high deductable for other care up to a certain limit (maybe $5000), at which time the insurance would kick in to cover the cost above that amount. That way, patients are encouraged to consult with their doctors about their options, and then if they choose to pursue more diagnostic tests, the patient would pay for them. But, in the case of injury or severe illness, the insurance company would pay.

Is that plan perfect for everyone? No. But the key point is that if consumers had a choice, they would find the plans that offer the best care at the lowest price for their situation, just like every other industry.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

It's about power. I've heard that many doctors have gigantic egos and hierarchical in power structure and can go from friendly to monsters very quickly if it looks like they are doing something wrong. The idea that a nurse could stop everything and tell him he (or she) had to follow some list…if it was an administrator on the floor that is one thing, but a nurse?

But there were also many steps, and forgetting even one could be fatal for the patient. Pronovost monitored actual behavior and found that while of course everyone (both doctors and nurses) knew what they were supposed to do, occasionally one little step would be skipped or reversed, and it was then not sterile.

The article has an interesting claim — that some of the best pilots in the world died before they made preflight checklists mandatory. True nearly all of those things are basic too (especially when you've flown the same plane over and over) but there are just so many steps it's easy to forget.

Pronovost’s solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost’s checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them.

And:

How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here’s an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people.

More:

How does a nation that might close down a business for a single illness from a suspicious hamburger tolerate the carnage inflicted by our hospitals?

Is it really true that 100,000 people die every year because doctors feel belittled by the requirement to wash their hands, a technique whose usefullness was established in the 1840's?

Any real fix is going to be very complex, and in a “need based” market that requires expertise beyond the ken of most people, that fix is not likely to be one of letting individuals make price based decisions. When the emergency hits, most will spend whatever it takes. Cost is not a controlling factor in an emotionally traumatizing situation like cancer diagnosis, car wreck, broken bone, swine flu or whatever.

The system is out of control with excess diagnostic tools that MD's are pressed to use, variable community standards for what constitutes malpractice, inefficient multi-system billing procedures and codings for each different insurance company and gov't program. I just don't see a good option that doesn't involve some intervention, and it probably needs to be national in nature.

Isn't this the problem in a nutshell with government regulation? And you seem to be a proponent of having a nationalized public option, tidbits (or at least not opposed to it) yet you already described the same problem in a state legislator level that is so apparent among our national legislators (and chief executive, frankly- I'm appalled at some of the statements that Obama has made about healthcare delivery which show almost no understanding of the system and use inaccurate examples to even try to describe a few of the real cost problems.)

Regulation itself isn't good or evil. It's sometimes necessary, but quite often it's done poorly. Anyone of the liberal/progressive mindset who believes that more regulation is the answer needs to own up to the fact that this means that we need to elect people who know what they are doing- they have to have some expertise in the area that they're writing legislation for.

When the legislators don't understand the real issues, they do tend to kowtow to the larger corporations. If they understood where the real barriers to competition were, they'd be able to regulate in sensible and needed ways which would actually help smaller businesses and start up entrepreneurs compete. Instead, most regulation hurts the little guy far more than it stirs competition for the large players.

Actually, I've read (and surprisingly it was by the pro-reform cover everyone groups) that in aggregate preventative care is not actually cheaper. Sure it is true on the individual level, and leads to increased quality of life for nearly the same cost (so it should obviously be encouraged) but it shouldn't be seen as a cost reducer.

I do believe that if the government ran the catastrophic health care and that there were HSAs to cover the medium cases (like when I got an appendectomy) and a direct subsidy for the poor to get routine care, then things may work better. You obviously missed the part where he said it'd be cheaper for the government to just pay for routine care every other year for those that can't afford it as a benefit similar to food stamps…so he wasn't trying to hang them up to dry. And honestly, people that can afford it already spend several hundred bucks a year in deductibles, I doubt they'd stop.

With that said, I think he goes too far to suggest that insurance should only be for catastrophic coverage. There are two problems I see with this:

1) Exactly what is “catastrophic” is not easy to define. What about people who are chronically ill? They may not need some major surgery or urgent life-saving care, but they may need much more frequent doctor's visits, which might be considered routine care that would not be paid for.

2) This would encourage people not to seek care when they have a minor problem which could be a sign of a larger problem. The article implies that this would lower costs, as the demand for health care would decrease. However, it ignores the common view in the health care world that preventative care is (normally, not always) cheaper that reactionary care. Dr. Goldhill compares the current system with an auto-insurance company paying for your gas. But I don't agree with his analogy. If you don't fill your car with gas, the car will quickly stop running. But if you don't see your doctor for routine visits, you might be fine for a while, but could eventually end up with a bigger, preventable problem that your insurance plan will have to pay for.

So, I don't support measures to move us toward more of a catastrophic insurance system. It is in the interest of the patient and the insurance company to make sure the patient is getting routine care, and so covering that cost, to some degree, makes sense.

But, as I said, I agree with his basic point that the lack of consumer input drives up the cost. So what would I do? Allow the consumer to have more choice in the insurance market. Patients might not have the technical expertise to choose specific treatments for themselves, but at least they should have a wide array of choices with regards to the plan they sign up for. Our employer-based system, as well as excessive government regulation, severely limits consumer choice in this area. Most of the complaints about insurance companies could happen in any other industry, except that in other industries if the customers are not happy, the company goes out of business because the consumers go elsewhere.

I do think some regulation is necessary, especially with regards to how insurance companies calculate premiums and deductibles. An effective free market should reward good decisions and punish destructive ones. But in the health care industry, a pure free market severely punishes those who have the nerve to get sick, which clearly is not desirable. The free market is a means to an end, not an end by itself.

The average voter's memory is increasing from the old days of just five years or so. With the internet we've got constant reminders from things that happened 20 and 30 years ago right at our fingertips via search engines. We can even compile lists to publish later at election time [maybe just the night before in a blitz] of who offered nothing or business as usual and who instead offered compassion and a solution to the problem.. Sleep well knowing your jobs are on the line.

Each of the fifty states regulates health insurance differently. And because state legislators know little or nothing about health insurance, almost all of those regulations are written by health insurance lobbyists. That means they are written in the interests of the insurance industry, not the health care consumer.

Honest. competent government puts the people first and profit motive second when the two are in conflict.

This fiftty state mish-mash has created havens for particular ins companies in some states and other ins companies in other states. It discriminates against those with pre-existing conditions, those over the age of 45 whose premiums sky rocket, includes “recission” provisions to avoid payment on legitimate claims and “wastes” as much as 30% on administrative expenses while focusing on finding excuses to deny payment rather than providing care. That is not a system worthy of capitalist non-intrusion.

When an industry becomes that morally bankrupt, the people have a right to intervene in their own interest. The current variant of the health care plan may not be the correct one, but it is a start. FT's idea of limiting profit margins may not answer every question (especially with the creative accountants these ins giants can employ) but its better than suggesting no solution.

Thisi s a problem that needs to be solved to prevent the bankruptcy of our nation and its people. To Hell with Fidel and all the partisan crap. What's your solution to the problem, other than the medical industry being entitled to happiness…read unwarranted profits… at the expense of disease, death and lack of adequate medical care for a significant percentage of the American people?

Not all “health insurance” is alike, but only after someone needs to sue it, do we know what deals they have cut with what doctors or hospitals.

But as the author mentioned, in his place nobody cares, yet they are suopposed to care five yeras kater.

Same with the consumer aspect. Of course we need to have better information and see how that affects things because there is a gigantic improvement to be had. On the other hand, I'm not sure that it is the primary cause of the problem (although it's hard to know since that data isn't really available) and as such I don't think it should be made the main focal point of the health system.

That said, it seems increasingly clear to me that these “conservative” reforms are necessary first steps to even figure out what really is driving health care costs.