What you can do for your country

A Doctors View: Government healthcare already rations

From an E-Mail I received....

This letter is from Dr. Zane Pollard. He is operates at Children's Health Care of Atlanta. Google him, he has a very impressive CV.

http://www.eyeconsultants.net/pollard.html

http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/Dr-Zane-Pollard-MD-36307DFF.cfm
 
Friends:
 
I have been sitting quietly on the sidelines watching all of this national debate on healthcare. It is time for me to bring some clarity to the table and as your friend by explaining many of the problems from the aspect of a doctor.
 
First off the government has involved very few of us physicians in the healthcare debate.While the American Medical Association has come out in favor of the plan, it is vital to remember that the AMA only represents 17% of the American physician workforce.
 
I have taken care of Medicaid patients for 35 years while representing the only pediatric ophthalmology group left in Atlanta, Georgia that accepts Medicaid.Why is this. For example, in the past 6 months I have cared for three young children on Medicaid who had corneal ulcers. This is a potentially blinding situation because if the cornea perforates from the infection, almost surely blindness will occur. In all three cases the antibiotic needed for the eradication of the infection was not on the approved Medicaid list. Each time I was told to fax Medicaid for the approval forms which I did. Within 48 hours the form came back to me which, was mailed in immediately via fax and I was told that I would have my answer in 10 days. Of course by then each child would have been blind in the eye. Each time the request came back denied. All three times I personally provided the antibiotic for each patient which was not on the Medicaid approved list. Get the point--rationing of care.
 
Over the past 35 years I have cared for over 1000 children born with congenital cataracts. In older children and in adults, the vision is rehabilitated with an intraocular lens. In newborns we use contact lenses which are very expensive. It takes Medicaid over one year to approve a contact lens post cataract surgery. By that time a successful anatomical operation is wasted as the child will be close to blind from a lack of focusing for so long a period of time. Again extreme rationing.  

 

Solution- I have a foundation here in Atlanta supported 100% by private funds which supplies all of these contact lenses for my Medicaid and illegal immigrants children for free. Again waiting for the government would be disastrous.
 
Last week I had a lady bring her child to me.They are Americans but live in Sweden, as the father has a job with a big corporation. The child had the onset of double vision 3 months ago and has been unable to function normally because of this. They are people of means but are waiting 8 months to see the ophthalmologist in Sweden. Then if the child needed surgery they would be put on a 6 month waiting list. She called me and I saw her that day. It turned out that the child had accommodative esotropia (crossing of the eyes treated with glasses that correct for farsightedness) and responded to glasses within 4 days, no surgery was needed. Again, rationing of care.
 
Last month I operated on a 70-year old lady with double vision present for 3 years. She responded quite nicely to her surgery and now is symptom free. I also operated on a 69-year old judge with vertical double vision. His surgery went very well and now he is happy as a lark. I have been told--but of course there is no healthcare bill that has been passed yet--that these 2 people because of their age would have been denied surgery and just told to wear a patch over one eye to alleviate the symptoms of double vision. Obviously cheaper than surgery.
 
I spent two years in the US Navy during the Viet Nam war and was well treated by the military. There was tremendous rationing of care and we were told specifically what things the military personnel and their dependents could have and which things they could not have. While in Viet Nam, my wife Nancy got sick and got essentially no care at the Naval Hospital in Oakland, California. She went home and went to her family's private internist in Beverly Hills. While it was expensive, she received an immediate work up. Again rationing of care.
 
For those of you who are over 65, this bill in its present form might be lethal for you. People in England over 59 cannot receive stents for their coronary arteries. The government wants to mimic the British plan. For those of you younger, it will still mean restriction of the care that you and your children receive.
 
While 99% of physicians went into medicine because of the love of medicine and the challenge of helping our fellow man, economics are still important. My rent goes up 2% each year and the salaries of my employees goes up 2% each year. Twenty years ago ophthalmologists were paid $1800 for a cataract surgery, and today $500. This is a 73% decrease in our fees. I do not know of many jobs in America that have seen this lowering of fees.
 
But there is more to the story than just the lower fees. When I came to Atlanta there was a well known ophthalmologist that charged $2500 for a cataract surgery as he felt the was the best. He had a terrific reputation and in fact I had my mother's bilateral cataracts operated on by him with a wonderful result. She is now 94 and has 20/20 vision in both eyes. People would pay his $2500 fee. However, then the government came in and said that any doctor that does medicare work can not accept more than the going rate (now $500) or he or she would be severely fined. This put an end to his charging $2500. The government said it was illegal to accept more than the government allowed rate. What I am driving at is that those of you well off will not be able to go to the head of the line under this new healthcare plan just because you have money as no physician will be willing to go against the law to treat you.
 
I am a pediatric ophthalmologist and trained for 10 years post college to become a pediatric ophthalmologist (add two years of my service in the Navy and that comes to 12 years). A neurosurgeon spends 14 years post college, and if he or she has to do the military that would be 16 years. I am not entitled to make what a neurosurgeon makes, but the new plan calls for all
physicians to make the same amount of payment. I assure you that medical students will not go into neurosurgery and we will have a tremendous shortage of neurosurgeons. Already the top neurosurgeon at my hospital who is in good health and only 52 years old has just quit because he can't stand working with the government anymore. Forty-nine percent of children under the age of 16 in the state of Georgia are on Medicaid, so he felt he just could not stand working with the bureaucracy anymore.
 
We are being lied to about the uninsured. They are getting care. I operate at least 2 illegal immigrants each month who pay me nothing and the children's hospital at which I operate charges them nothing also. This is true not only on Atlanta, but of every community in America.
 
The bottom line is that I urge all of you to contact your congresswomen and congressmen and senators to defeat this bill. I promise you that you will not like rationing of your own health.
 
Furthermore, how can you trust a physician that works under these conditions knowing that he is controlled by the state? I certainly could not trust any doctor that would work under these draconian conditions.
 
One last thing, with this new healthcare plan there will be a tremendous shortage of physicians. It has been estimated that approximately 5% of the current physician work force will quit under this new system. Also it is estimated that another 5% shortage will occur because of decreased men and women wanting to go into medicine. At the present time, the US government has mandated gender equity in admissions to medical schools. That means that for the past 15 years that somewhere between 49 and 51% of each entering class are females. This is true of private schools also because all private schools receive federal fundings.
 
The average career of a woman in medicine now is only 8-10 years, and the average work week for a female in medicine is only 3-4 days. I have now trained 35 fellows in pediatric ophthalmology. Hands down, the best was a female that I trained 4 years ago--she was head and heels above all others I have trained. She now practices only 3 days a week.
 
Zane Pollard, MD 

http://www.eyeconsultants.net/pollard.html 

 http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/Dr-Zane-Pollard-MD-36307DFF.cfm

Democratic investigators target health insurers to access proprietary corporate data and advantage government program: Antitrust?

Democratic investigators are targeting health insurers, asking for a range of information on critical operational data including:

• Executive Compensation
  • Salary
  • Bonus
  • Stock Grants
  • Realized value of options
  • non-equity compensation
  • Pension value/Deferred compensation
  • All other compensation
• A list of all board members and their compensation
• List of all conferences, retreats, events, etc that were paid for by the company.  Include purpose, participants, expenses, transportation, etc
• For 2003-2008 list
  • Total revenues
  • Net Income
  • Total Dividends
• Documents provided for the board, compensation committee, models, projections, performance criteria, etc.
• For 2005 - 2008, a table listing premium revenues, claims, payments, sales expense, other G&A and profit for all the companies health insurance products.  Aggregate by
  •  Self insured employer market
  • Insured employer market
  • Individual market
  • Government market (Medicare etc)

Now some of this is public data and readily available, so Congress could have found it the same way the rest of us get it, via a 10k.  But a bigger issue is Congress wants to go into the health care business, with the public option.  Can you imaging IBM sending Apple a request to provide all their private competitive data so that IBM can build a competing product to the Iphone?  No.

If government wants to offer health care, they need to get out of the regulatory business.  Or be a regulator, not a health care provider.  Most people would call this request a mater of anti trust.  Waxman thinks its OK to get this data because, hmmmmm......   well I don't know why. 

If this is the way congress acts before health care reform, just think what will happen after once there is no going back. 

The public option is supposed to stand on its own.  That should mean, it competes in the marketplace based on paid insurance plans, without impinging on the rest of the insurance market.  So, hospitals should not be able to cost shift government underpayment of claims by increasing fees on private insurance patients.  Similarly, congress can't use private corporate data to structure a program that will directly compete with private insurers.  Its not fair.  It is theft of valuable data.  

If I were an executive I would tell them to go look at my company 10K, and pound sand.

How Health Care is Killing Us (Government Advocates Mediocrity in Land of Innovation)

I have been working on crystallizing my thoughts on how to fix health care.  I am frustrated that the proposals in Government all seem incremental, taking the solutions we have but locking them in under yet more centralized government control.  We are the most innovative and productive nation on earth, but we seem ready to fix health care by expanding the status quo and replicating the plans of other lesser countries (Europe, Canada, Etc).

I received my issue of the Atlantic last night on my Kindle DX and found the article I wish I had written:  How American Health Care Killed My Father - The Atlantic (September 2009).  The author very thoughtful integrates his business experience, loss of his father, and political thinking into a very complete approach for health care that drives consumer choice, reduces cost and motivates innovation.

  Key highlights of his article include:

• Why do MRI prices (Covered expense) remain high years after introduction while Lasik surgery (non Covered Expense) has dropped from $2000 to $400?
• Why vilify the profits of health insurance companies when they would pay 4 days of our nation's annual health care costs?
• We don't use auto insurance to pay our gasoline costs, why do we use health insurance for paying routine health costs like checkups?
• Do government regulations limit innovation?
• Why can't a consumer ever find out the cost of a procedure upfront?  How can cost be managed if the customer of the care can't even see the cost?
• Over the life of a typical employee, $1.77M is paid into health insurance (employee and company payment together).  If we gave everyone $1.77M, could they do a better job managing it?

In health care, the notion of a free market seems foreign to some.  Won't those companies cheat individuals?  Insurance companies and doctors can't possibly do what is right for the patient in a free market because they will just be focused on making a $.  The reality is the market is already being perverted in various ways depending on the direction of various regulations about what can or can't be funded.  Hospitals do everything they can to squash new innovative surgery centers that are set up to take advantage of Medicare's unwittingly payment of higher margins on lower end surgical procedures.  Loopholes will all ways be found in every system.  But can they be corrected quickly?  Only in a market based system.

Government has a key role in assuring integrity and standards in the system, but price really should be a function of consumers engagement with doctors to determine the best price, innovation and quality.  Because of constraints driven by Medicare and insurance companies, the most costly health care is typically someone who pays out of their own pocket, but those same people are probably the cheapest people to treat because the doctor does not need to file claims etc.  This is a market perversion driven by a top down driven regulatory environment.

The author goes on to suggest the broader implementation of Health Savings accounts, a form of major medical insurance that kicks in for the absolute worst case tragedy that costs more than 50K (with no cap), and various other thoughtful modifications.

Between the Atlantic Article, the WSJ OpEd article from Whole Foods CEO, and the plan at Safeway, exists an answer to health care I can live with that will drive innovation, reduce cost, and expand coverage.

What is more important personal freedom or universal care? A test for Obama

I think we can all agree that we want people who are sick to get better, to have access to good health care and to not suffer due to health ailments.  But can we also agree that we believe in personal freedom, the right to make decisions for ourselves? 

Yes, Canada, England, Europe, China etc all have some form of universal health care.  That is great.  They also have limitations to a free press, less innovation, bad economies and less freedoms.  The United States represents 26% of world GDP.  The next largest economy is 1/3 the size of the United States.  The United States went from a start up 230 years ago to the most powerful country in the world.  Did that happen because of the greatness of our government actions or the greatness of our people?  Should the United States follow the path of others, or set the course for others as we have since our inception.  Our personal freedoms and rights to see opportunity, gather and engage each other, partner and invest, and think and dream are just an element of what makes the United States truly unique.

The health care debate is a foil to help us reflect on our rights and personal freedoms.  The President tells us, (Paraphrase) "...Health care is a mess and we need to take immediate action or it will collapse...".  If true, that is bad.  Though it is unlikely true.  I am not sure I know of any period in our country's history where our ability to address a challenge lead to total failure.  We were close in the depression and the cival war, but only close. 

I would argue, innovation and personal freedom have always been a correcting force for government failure.  Isn't that what democracy is about?  We the people have assigned some of our rights to the government because it is easier to manage.  We get to pick the managers.  And if they don't do a good job, we will fire them.  We only gave them some rights, not all.  We reserved all other rights to ourselves, and we are not going to give them up without consensus (i.e. constitutional convention).  Ronald Regan reminded us in 1961 about how subtle encroachment of the state can weaken our rights over time:

"One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can’t afford it." Ronald Reagan - 1961

With all the noise on health care and distraction of Nazis, socialism, the bill is not decided, republicans are racist, etc, part of my discomfort with the debate has crystallized around a WSJ article about the President regarding end of life care.  The President starts of the interview....

The President: "Now, I actually think that the tougher issue around medical care—it's a related one—is what you do around things like end-of-life care."

Yes end of life care is tough, each of has had to deal with it in some manner (Wife, Child, Mother, Grand Parent)

The President: "...I just recently went through this. ....when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip.....

So now she's in the hospital, and the doctor says, Look, you've got about—maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that—you know, your heart can't take it. On the other hand, if you just sit there with your hip like this, you're just going to waste away and your quality of life will be terrible. And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just—you know, things fell apart.

I don't know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn't have a hip replacement and she had to lie there in misery in the waning days of her life—that would be pretty upsetting.

So the President seems to get that end of life care is tough.  He would have personally paid.  But then he goes to statism, questioning if "...a hip replacement when they're terminally is a sustainable model, is a very difficult question..."  Difficult question for who?  The government?  Society?  Its not their question.  Government, Society, everyone (except for the patient and maybe their family) has no right whatsoever to any part of the discussion.  None!  Nothing!  Nil!.  The constitution has provided no power to anyone to infringe on ones personal rights for what to do next with their life.

Recognizing the impact on cost of care, the President goes on:

The President: "Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicist. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance. And that's part of what I suspect you'll see emerging out of the various health care conversations that are taking place on the Hill right now."

Guided by doctors, scientists and ethicist?  They will guide the decision about how we mange end of life decision on the economics of care?  Really?  What about the patient and their family?  The President says he would have "paid out of pocket for his grandmother", but wants doctors, scientists and ethicist to guide for the rest of us under the health care bill.  Did we ask for this help?  If we did not ask for it, why do we need it?  Probably because, the only way to run a government program is to cut cost, and the only way to really cut cost with out innovation is to pull the plug on Grandma.  (But he didn't say that right?)

What the health care bill contains and the degree to which the public option restricts funding certain treatments does not really matter if other options exist (secondary insurance and paying cash).  Practically it is hard to believe that the government will close down the right to supplement ones health care.  In a market economy though excessive government restrictions may very well shut down private options.  But what is outrageous is that the government thinks it even has the right to implement a health care program, using public resources, that restricts personal choice.  (all must opt in and follow the "Plan").  Furthermore, it is outrageous for the government to do anything that impinges on our rights to buy insurance (opt out) from other health care innovators.  Impinges includes restricting how other insurance plans can operate, who they enroll, what preconditions they accept, etc. 

The great thing about the "Market" is that people have the right to choose.  People do not have a constitutional right to government funded end of life care.  People have the right to choose if they want to use their resources to buy insurance and/or pay extra out of pocket for grandma's care.  They have the right to choose that independent of the government, doctors, ethicists, and scientists. 

In sales mode, the President keeps saying the choice for end of life care is between the doctor and the patient, not government or private insurance (making some veiled comment that somehow insurance companies already restrict rights).  Private insurance is really not currently involved in the decision.  They contribute, via a contractual relationship, to the decision in their willingness to fund a portion of end of life care, but they don't have ethicist making the decision for patients or ethicist deciding on a formulation for what can/can not be funded.  The calculus of what is paid for at end of life is a result of an economic decision between the insurance company and the patient.  And, really end of life care decisions are not the doctors prerogative.  I have had these conversations with regarding my mother with docotrs (sample size 1) and never found them steering me in any direction.  The Doctors left the decision to the patient and family.

I am pretty sure the President Obama is president of the United States, not the CEO of a new health care company.  I don't think he is a doctor, though he seems to think he knows how doctors should practice medicine.  Since he is president, he should focus on first preserving our rights to personal freedom i.e. "First do no harm".  In the context of Health care, he should preserve our rights to have a competitive health care market that maximizes the ability for patients to choose.  Health care should not be about society choosing/limiting our options through government regulations.  That might work for Europe, Canada or China, but the United States is made of different stuff. 

Through personal choice we have created the most prosperous country in the world, driving unbelievable levels of innovation and opportunity.  The WSJ interview with the President signals that he is a man that believes Doctors, Scientists, and Ethicists can shape the best decisions on our behalf forgetting that its individual freedom that made us great.  He needs to choose between Statism and personal freedom.  I have.  We can innovate our way through this problem if he gets out of the way.  That would be the honorable path to universal health care.

Obama's healthcare horror (Heads should roll -- beginning with Nancy Pelosi's)

Camille Paglia wrote a great article in Salon, critical of the health care plan.  Critical from the sense of, Health Care is an import issue to address so don't waste the opportunity to do it right.  She goes on to outline how the President is being poorly served by his staff and congress.

As an Obama supporter, she describes her frustration with the hard push to agree on a health care plan despite limited debate.  She contrasts the "Its in there don't worry" repose of government despite the fact that there are 5 competing health care bills, no one of which is near settled.

I believe the anger we are seeing in town halls is pent up frustration, from the Stimulus bill on.  Statements like "The economy is getting better because of Stimulus", when less than 10% of stimulus has been deployed, makes you wonder if the rest of stimulus is needed.

I am frustrated that the president says "If you like the health care you have now, you can keep it", when HR3200 outlaws Health Savings Accounts, which is my current health care plan.  I am not sure who to believe or trust when there are so many blatant contravening facts and assertions.

Ms. Paglia does a good job capturing the frustrations of many.

Obama Says "CBO not Telling the Truth on HealthCare" - Elliot Richardson where are you

Well, in an effort to push health care, it seems the only Truth is what comes out of the mouth of Senator Reid or the President, everyone else is not telling the truth or is a partisan.  Reported in todays Washington Post, President Obama "Urged Congress to push past growing doubts......"

As you likely know, the Congressional Budget office, an organization intended to review and assess the impact of legislation, stated something to the effect that the current health care bill moving though congress would likely increase the cost of health care and increase the deficit.  The CBO issued a 17 page report making several important observations:

.....Among other things, the legislation would establish a mandate for legal residents to obtain health insurance; set up insurance “exchanges” through which some individuals and families could receive subsidies to substantially reduce the cost of purchasing insurance; significantly expand eligibility for Medicaid; make modifications to the Medicare and Medicaid programs; and impose an income-tax surcharge on high-income individuals....

....CBO’s and JCT’s preliminary assessment of the impact on the federal deficit for the bill as introduced is summarized in the following table. The enclosures with this letter provide estimates of the changes in the nonelderly U.S. population with health insurance coverage, the primary budgetary components of the bill’s major provisions related to insurance coverage, and a detailed table of the other provisions’ impact on federal direct spending. The estimated impact of the provisions related to health insurance coverage is based on specifications provided by the committee staff, rather than on a detailed analysis of the legislative language....

Even with a bunch of other revenue increases and savings from other government programs CBO concluded...

...According to CBO’s and JCT’s assessment, enacting H.R. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010-2019 period. That estimate reflects a projected 10-year cost of the bill’s insurance coverage provisions of $1,042 billion, partly offset by net spending changes that CBO estimates would save $219 billion over the same period, and by revenue provisions that JCT estimates would increase federal revenues by about $583 billion over those 10 years.....

This report from the CBO was signed by Douglas Elmendorf, a former Clinton administration economist who was appointed to lead the CBO by the current Democrats in Congress.  So, the democrats appointed the guy bearing bad news.

As written on the CBO website....

CBO's mandate is to provide the Congress with:

Objective, nonpartisan, and timely analyses to aid in economic and budgetary decisions on the wide array of programs covered by the federal budget and

The information and estimates required for the Congressional budget process. So, what

As Reported by MSNBC....

"The New York Times writes that the Congressional Budget Office’s Douglas Elmendorf “told Congress that the health legislation proposed so far would not curb the federal government’s runaway spending on medical care and that lawmakers would need to take more forceful action to meet Mr. Obama’s goal of controlling costs. The testimony by Mr. Elmendorf before the Senate Budget Committee drew criticism from Democratic leaders, highlighting their rising frustration over the difficulty of paying for an overhaul. Asked about the testimony by Mr. Elmendorf, a highly regarded economist, the Senate majority leader, Harry Reid of Nevada, snapped derisively, ‘Maybe what he (Elmendorf) should do is run for Congress.’”

And as reported in the Washington Post and other outlets President Obama said "That's Simply Not true" in regard to the CBO's assessment and its forecast of deficits.

So apparently the President and Senate Majority leader, believe the Democrat's appointed head of the CBO should either run for congress or stop lying.  I know its not the CIA lying to congress but can we stop attacking the messenger.  Apparently the President and Reid, both partisans, know more about economics than an Economist (Elmendorf).

One would have hoped that maybe Reid and the President could have said "The conclusions by the independent assessment arm of the Congress, the CBO, has raised some concerns about the affordability of health care.  The Bill is still evolving.  We look forward to their future assessments and will work hard to successfully address the CBO's concerns".  I mean, isn't that a bit nicer way to say you disagree with someone. 

This is not Pelosi saying the CIA lied, but at some point we need an Elliot Richardson moment where someone stands up and calls out congress and the president on the sham they are shoving down our throat, called healthcare reform. 

Do you know your cost of Health Care? A reality test for congress

I have often thought that a basic problem with health care is insurance.  That insurance, promising full coverage for those with the right employer, motivates bad behavior from customers and doctors.  Why be a savvy shopper when all health care is free?  This is often referred to as moral hazard, one abuses a resource if there are no repercussions.  Conversely, the need to mitigate health care cost (counter moral hazard) has been regulating price, not paying more than $X for a given procedure.

In most other markets this combination of moral hazard and cost constraint, slows innovation.  Why innovate if I can't sell more product and make more money?  If the customer can't decided on procedure, why offer any options?  If there are no options, there is not concept of early adopters willing to pay a bit more for a more innovative product, that might not be perfect but none the less appealing to savvy shoppers (like the folks that bought an iPhone before it was a cool idea, in my case it was testing for CRP before it became a routine blood test).

I am a student of innovation.   A true believer in the concepts of Creative Destruction (Schumpeter et. al.)  What that all means is that if a buyer and seller can negotiate different options of what might be bought, then over a period of time better products will emerge and people will learn what is the best product, in terms of the needs of the customer (not some actuary in a tower).  And, as early adopters consume products, costs will come down and quality will go up.  For example, a $1,000 Dell computer today can do more than a $1M cray computer could do in 1980.

So, I have been testing the health care industry.  I have my own insurance and use a Health Savings Account.  Essentially this lets me put $2,500 into an account pretax and increases my deductible to $2,500.  My overall insurance cost is much lower, but I am at risk in a sense for the first $2,500.  So, I am now a consumer.  I want to know how much everything costs, what its value will be, and wish to know more about my options. 

So, here is my story.  I go to a specialist today.  He looks at my problem and says "I can do either A or B.  A may work.  B definitely will work.  What do you want to do?"

So, I say "Choice B, but what does it cost?".  The doctor says "What does it cost?  Hmm.... I don't know?  Maybe my Administrator knows". 

I go to the administrator, "What does it cost?".  The administrator says "Well, the doctors cost or the other costs for the procedure?  I am not sure?  You need to call the place the procedure will be done?".  I am thinking, "My cost.  Why do I care what the doctor gets paid.  And why do I need to call the surgery center where the doctor plans to do the procedure."

Would you buy a car without knowing what it costs?  A house?  A cell phone?  When doctors don't even know what the cost is, how can some remote bureaucrat figure it out accurately?   And by cost I mean A vs. B.  I am making the A vs. B decision.  The Insurance company might set a rate for A or B, but they really have a hard time forcing my hand if the difference is marginal.  They are just not that good at understanding my "Reservation Price" and other related costs.

The way you control cost and quality is to establish a relationship between buyer and seller.  Period!  Some will say "But this is not a normal transaction, if you get ripped off its your health and you die".  Well maybe you do, but you also die by having piss poor doctors that are not motivated to make more money, do better for themselves and the patients.  I want people who work for me to make money, because then they work harder for me.  People judge their self worth and learn to do better by the interaction they have with those around them.  If you are a smart person thinking about a great profession, do you want to get a job where your hard work pays off or where you just follow a routine and have a defined revenue stream (Defined by Congress).

I personally think we would all be better with an HSA.  The $2,500 deductible can be managed in almost all cases, low income can have their payment subsized by tax payers and the rich can self fund.  We would each become more aggressive about our health care, limit our use to when we really need care, and in so doing become a more active participants in the health process.  The ensuing competition would continue to motivate good people to enter the profession.  And, most importantly of all, through innovation, what amounts to $1M Cray computer in health care (i.e. liver transplant or such) will over time come down in price (quickly with innovation) because smart doctors will figure out better tricks and tools for driving better care, because their patients reward them for it monetarily and through the customer/supplier relationship of commerce.

So, your homework assignment - when ever you go to the doctor (if you are paying or not), ask what it costs.  See what you find out.