Although I detest health insurance companies intensely (obviously, I'm an objective fellow) and think they should all be sent to bed without their supper, there is another way to view them, as the entity our employers contract to deny employees coverage and contain our employer's costs.

Our employers obviously can't pay for unlimited healthcare for everyone and stay in business, so health coverage is usually "Tiered." "C" level types (CEO, COO, CVO, CIO, e-i-e-i-o) might have unlimited coverage, even for hangnails and ennui.

Tier 2 employees, high-paid or skilled, upper-middle management, might get the same drug coverage as the big wigs EXCEPT for, perhaps, the 100 most expensive drugs, which are on some type of approval list (I think that means the insurance companies just laugh hysterically when you try to get them approved.)

Tier 3, however it's defined, has lower reimbursements for some procedures, some procedures are excluded, and more drugs have to go through some "step therapy" as one company calls it, which is that approval for the drug your clinician prescribed is Step 3, but you have to go through Steps 1 & 2 and prove they don't work before you can have it. Step 1 might be taking aspirin, even if your condition is that your platelettes aren't sticking together properly (that probably doesn't make sense). Step 2 might be sitting in a forest, thinking calm thoughts while your insurer throws heavy rocks at your head. And, if your physician will verify that Step 1 didn't work, and Step 2 didn't work, you might, but only might, get a 6-month approval for a condition you have for life. I used to go through this but now just buy non-covered drugs in Mexico for a small fraction of what my local drugstore charges.

So insurance companies, as much as some of us hate them, are essentially doing what their customers (employers) tell them to do: limit costs by denying certain procedures & medications and other things. If you look at your health insurance card, if you have one, you can usually tell what coverage tier you are in.

Of course, the best system would eliminate health insurance companies all together, but I fear we're going to go through Tier 1 and Tier 2 attempts at reform before discovering what all those other countries, with imperfect but clearly superior systems, have already discovered. Such is life.

Just to say I agree with you, but would also point out that physician and surgeon salaries are not what they used to be. They've been part of the cost containment and millionaire doctors aren't littering this country's healthcare locations. My primary care doc, married guy, one child, sole income, is also a friend of mine & every time I see him he observes he went into the wrong profession as he'll never be able to afford a car like I have (we Cali folks are into cars). He's joking, but there's a lot of truth there.

Great info. It will be interesting to see how the healthcare transition team, whoever they are and whatever exactly they do, take advantage of the fact that almost all of the 5,000 or so recommendations and comments in this blog have not only been discussed but studied and the results reported. This is one issue where data exists and can help make informed decisions.

I only have one note for my responses, but government-financed universal care for all citizens, the same system working in so many other countries, would resolve so many of these issues, and resolve them completely. I actually thought that's what Pres. Obama was running on, but of course actually reading the plan I see our friends, the insurers, are still there and there's still the tremendous additional cost of doing business as essentially health care insurance workers. It's sad to think after all this work there will still be claim forms, employer "sign-up" period, insurance company refusals (or the game of refusing 2 or 3 times then OK'ing it), and so many other problem. Rather than "Healthcare for All" perhaps it could be called "Healthcare Problems for All."

Hi

Thanks for the reply. I must have mistyped as I'm very much in favor of the she, which is usually stored at the comers of the healthcare system. I do like to try to introduce some of my learning from doing this stuff. Will we use the emr from the va or go commercial. Will we standardize on a system. Studies have shown physicians using emr's have better outcomes. However those of us who have actually installed these systems will tell u it's no picnic and runs afoul of many physicians, but of course it gets done. Emr's r a great idea. 

Chrome is working real well; there just aren't the features available that I'd like. But the Chrome browser is building the pages & navigating very quickly.

It's difficult to change the Information Architecture of a site that already has active blogging, but I think that's the cause of the problems. For example, if you reformatted the terms cloud so you could click on the term where you last commented for follow-up, or where you wanted to comment, you would have essentially 5,000 messages with no differentiation to help you get to the right one. Simple tools like "Find _____ author" would help with navigation. The performance isn't the best; could be some slow fiber from the server to the world or just a lack of horsepower. The best thing is to let this run, keep up the progress while your design team and Web guru redesign the whole thing, go down for 12 hours overnight, and bring up a superior version 2, based on feedback. Kind of like what we want to do with healthcare! I also assume that, like most Web projects, the designers & sponsors may have underestimated the interest, which in a way reflects a good king of problem to have!

You can tell you're senile when you comment on your own comments, but I will just mention that salaries for top IT people in healthcare are lower than other industries, as you'd expect. So a great Systems Analyst or Internet Strategist might earn average money, in healthcare, but could leave & nearly doubt their salary. It's happened to me and members of my staff. I was thinking of applying to AIG -- I hear they're doing pretty well for cash on hand these days! A few IT superstars make a heck of a lot of difference in every system.

Just a few comments on technology. I've been the Exec Director of Emerging Technology, e-Medicine, and System-wide Internets, as well as being a consultant who recommended or saw the installation of EHR and other large med systems.

Healthcare has always under spent industries like the financial industry on Information Technology, usually by 1 or 2% of revenue. As a result, the systems are old, change slowly, don't work well, and are overly complex. Nor do they have adequate IT departments; the last hospital I worked at had an IT department of over 150 people. But I've consulted in hospitals with 2 FTE's

Security is a nightmare for all of us, but don't take it out on healthcare. Hackers go after big, public hits or places they can make a buck (banks) & it's usually to get the mailing list of the organization for spamming purposes. There is very little reason anyone would go after one person's health file, and remember we are hearing about people in the govt looking at Obama's passport and other records, and they did not hack -- they just looked. If I wanted your chart, I would put on a white coat, dummy up an id badge, wait until a busy time, and ask to see the PAPER copy, which is much more vulnerable than computerized records.

Clinicians, especially physicians, generally do not like automation or computerized systems. For some, the computerized systems gets in the middle or reduces the rapport with the patient during diagnosis. For some, they've never done it that way. For some, there's a discomfort level that everything they do (assuming you computerize order entry, charge capture and the ancillaries) is now available to anyone authorized to see that patient.

When these systems go in, which parts of which records you can appropriately look at is programmed right into the system, and if sensitive information is seen by ANYONE, even someone who's authorized to see it, a notification called a "breaking the glass" message is automatically sent to the appropriate people in the system, so even if you are authorized we keep track that you have seen a specific field (piece of information) within that system.

Nothing's perfect (except a blogger, perhaps!) but I think if you weigh the pros and cons, and have seen paper medical records sitting on a table at the hospital's McDonald's or heard docs discussing your health in the hallway, I think it's hard to disagree with a good medical record. And I haven't even gone on indefinitely as usual about how these systems help improve outcomes (which treatments worked and which didn't), and their value for epidemiology, research, etc.

Thanks!

I just want to say that I, too, was disappointed I didn't at least get a form e-mail rejection since I asked on several occasions to be part of this discussion, and my background is pretty good, and I have participated in other govt discussions of healthcare as an expert (got them fooled!) . But all of sudden we have Tom and the Ludmilla making videos & saying how nice it is to hear from us. But what's being done? How was the working group (?) or team (?) or committee(s) chosen & formed & how much is being done? No transparency here, unless this info is up & I just don't know where to look, in which case I apologize.

I don't get the purpose of this blog. If folks have been in healthcare for 10 or 20 years they've seen & heard all these ideas tens or hundreds of times.Some thousands. Some of these suggestions violate many healthcare regulations or are made in ignorance of half of the entities involved in Healthcare. There's an economics discussion I guess, but I won't comment there because I just don't know enough about the subject to talk with Allen Greenspan types and make any sense. There is likewise a lack of general knowledge of healthcare here -- I mean, "Crossing the Quality Chasm" was what, 5-6 years ago? We should at least be conversant with the literature, as people are giving thought, taking time and coming up with solutions. I doubt that's the intent, but who knows?

Is this a design phase? Feedback? -- but there's no "straw man" to make the feedback relevant. Granted, the members of the blog are obviously intelligent and articulate, but this is kind of "busy work" if we don't know what's happening, and if nothing is happening what's the point of all this "work" that's duplicative anyway? I'm assuming it's a kind of Pilot Project, for what I have no idea because it's not interactive. For a Web-Savvy campaign this isn't much of a blogging system, and "Search Clouds" are indeed pretty but they've been around for 2-3 years.

So I'm assuming there's a whole effort that's coming together, completely separate of anything on this site, to take advantage of Obama's "grace period," and can be presented in 90 or 120 days. And the effort has its act together because, as far as I can tell, there's nothing here that could stand up for 5 minutes against the Insurance lobby, Pharma lobby, and everyone else who's not going to like change. It's a really small window.