Updated August, 29, 2018.  Athletes, the entire athletic community and all citizens are impacted by the cost of healthcare, which is escalating disproportionately. Congress, healthcare personnel and many other concerned officials and citizens are evaluating and suggesting remedies for the healthcare problem.

Charles Krauthammer, M.D., psychiatrist, news columnist, opined that “prevention is a wondrous good, but in the total costs, it costs society more money.

“That’s the whole premise of medicine: Treating a heart attack or setting a broken leg also costs society. But we do it because it alleviates human suffering. Preventing a heart attack with statins or breast cancer with mammograms is costly. But we do it because it reduces human suffering.”

“The idea that prevention is somehow intrinsically economically better than treatment; that treatment increases costs and prevention lowers costs, is simply nonsense.”

A study in the Journal Circulation found that for cardiovascular diseases and diabetes. [The Impact of Prevention on Reducing the Burden of Cardiovascular Disease by Richard Kahn, Rose Marie Robertson, Robert Smith, and David Eddy 7 Jul 2008, Circulation]

“if all the recommended prevention activities were applied with 100 percent success,” the prevention would cost almost 10 times as much as the savings, increasing the country’s total medical bill by 162 percent.” [“Table 2, the prevention activities themselves would cost ≈$8.5 trillion, offsetting the savings by a factor of almost 10 and increasing total medical costs by ≈$7.6 trillion (162%)”]

Elmendorf additionally cites a definitive assessment in the New England Journal of Medicine that reviewed hundreds of studies on preventive care and found that more than 80 percent of preventive measures added to medical costs.

You will hear some variation of that claim a hundred times in the coming health care debate. Whenever you do, remember: It’s nonsense — empirically demonstrable and CBO-certified. [The “Preventive Care” Myth by Charles Krauthammer, Aug 14, 2009, Townhall]

“Cohen et al research analysis was restricted to the 599 articles and 1500 ratios published between 2000 and 2005 and classified 279 ratios as preventive because they refer to interventions designed to avert disease or injury; all 1221 other ratios pertain to treatments,

“Sweeping Preventive Care statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can significantly increase health care costs.”3

“Our findings suggest that the broad Preventive Care generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention.”

“In the face of increasingly constrained resources, there is a realistic way of achieving better health results: conduct careful analysis to identify evidence-based opportunities for more efficient delivery of health care, whether prevention or treatment, and then restructure the system to create incentives that encourage the appropriate delivery of efficient interventions.”  [Does Preventive Care Save Money? Health Economics and the Presidential Candidates
Joshua T. Cohen, Ph.D., Peter J. Neumann, Sc.D., and Milton C. Weinstein, Ph.D. February 14, 2008 N Engl J Med]

The following are suggested Healthcare system restructures. In actuality, these suggested restructures hearken back to fundamental cost saving healthcare 50 years ago.

1. Citizens must be educated, including face book memes and other electronic memes etc., beginning at an early age about the importance of their vital signs and the importance of their responsibility to have their vital signs determined once or twice each year.

Free or low cost Vital Signs Stations should be located in health departments, pharmacies, lobbies of hospitals, clinics, urgent care and other health care facilities and manned by qualified people. Vital signs measured should be: weight, pulse rate, respiration rate, blood pressure, temperature, visual acuity. Urine dip stick glucose for an extra minimal charge. Results recorded, maintained on site and copy given to patient.

2. ‘Cash and Carry Healthcare’ is one of many postulated healthcare remedies. This reporter practiced ‘Cash and Carry Medicine’ 1969 -1971 in rural Appalachia and cherished its simplicity and cost effectiveness, compared to the practice of ophthalmology for many years thereafter.

Dr. Forrest has published his excellent version of ‘Cash and Carry’ and readers should digest his splendid method of medical practice. [Cash and Carry Healthcare Has Evolved by Brian Forrest, MD, Dec 22, 2010 Volume: 21, Physicians Practice]

This reporter has a similar but different ‘Cash and Carry’ postulated medical practice method, probably over simplified, which follows. The following is also, as Dr. Forrest stated, a “low-overhead, direct-pay practice model” with “discounted cash rates, more time with patients” while practicing up-to-date, modern medicine.

The 3 potentially largest obstructions to economical, quality patient care in the practice of medicine follow.
1. Licensed doctors do not have to accept insurance or participate with insurance companies for reimbursement for patient office visits, examinations and treatments,
2. do not have to prescribe the most expensive medicine because of external or internal pressures
3. should not partner-up and/or be employed by hospitals on hospital campuses, if the Doctor then becomes beholden and obligated to practice as hospital administrations require them to practice.

A new and improved medical practice model is a necessity, beginning yesterday. ‘Cash and Carry’ and Concierge Healthcare are much less expensive and less intrusive than the current medical insurance Model, the Affordable Care Act.

“There is a predicted physician shortage ranging from 61,700 to 94,700 by the year 2025. [Association of American Medical Colleges (AAMC) 2015] 33% of physicians now over the age of 55 and due to retire soon.

The American Association of Medical Colleges, says by 2020, U.S. will need additional 91,500 doctors to meet medical demand.[9]

“Medical school admission is difficult. According to the Association of American Medical Colleges (AAMC), 53,042 prospective students applied to medical school in the 2016-2017 cycle, and a mere 21,030 students (40%) were accepted into U.S. programs. The average MCAT score for applicants was 501.8, while the average score for accepted students raised the bar even higher, to 508.7.”

“Acceptance into U.S. medical schools is becoming more competitive. In October 2015, the AAMC reported 52,550 total applicants, which is an increase of 6.2% from the previous year. Students applying during the 2017-2018 admissions cycle will likely see more of the same. [Medical School Admissions Trends to Watch in 2017, USNews]

While there are thousands of prospective student-doctors accepted to medical school, the number of openings and positions in schools will not be enough to fill the doctor shortage in 2020 with graduates to replace the shortfalls and retirees.

Yet, during the repeal and replace of Obama Care congressional fiasco, few legislators have mentioned the impact on Doctors from billing frustrations, government interference, government regulations, overwork, frivolous malpractice costly suits, escalating overhead, less time for patient care because of increased paperwork and many, many more grievances.

“Thousands U.S. Doctors now have concierge practices, which are rapidly increasing. Concierge medicine requires the patient pay an annual fees or pay for office visits at the time of service by cash, check or credit card with no insurance involvement for reimbursement for services rendered.” [Concierge Medicine Is Growing May 16, 2016, Physician Practice]

‘Cash and Carry Healthcare’ is a different system from ‘Concierge Medicine’, postulated to fill a Doctor-centered void in Obamacare. Hard to believe, isn’t it, that Doctors are part of the equation, who are paid primarily by overpriced insurance for over exasperated Doctors.

Historically, cash and carry is a system of wholesale trading whereby goods are paid for in full at the time of purchase with cash by the customer. For patient care cash nowadays, check and credit card would be received and prescriptions and treatments immediately carried away by the patient.

“In 2011 the average U.S. charge for an office visit for an established patient, level 3, requiring approximately 15 minutes with a doctor, was $104. The average total paid by the insurance company was $69. The following are some of the “Blue Book prices for doctor office visits:

“Office Visit, New Patient, Level 1 – Very minor problem requiring counseling and treatment, may require coordination of care with other providers – approximately 10 minutes with doctor – $68.

Office Visit, Established Patient, Level 5 – Complex medical problem(s) requiring comprehensive evaluation- approximately 40 minutes with the doctor – $234. Tetanus shot – $28.  Eye Exam, $234.New Patient

Private Insurance Deductibles, Co-Pays and Co-Insurance:  Almost all private insurance policies require the insured person to pay a co-pay when visiting a doctor or any other health care provider. The co-payment amount varies depending on the insurance plan. Typical co-pays for a visit to a primary care physician range from $15 to $25. Co-pays for a specialist will generally be between $30 and $50.

Most plans also require that the insured pay a deductible before the insurance provider will take over payments to a physician. Deductibles vary widely among plans, and some benefits may be available even before the deductible is met.

Also, co-pays may or may not be included in meeting the deductible. Co-insurance charges are usually stipulated as a percentage of the total bill. For example, an 80/20 policy is one in which the insured pays 20 percent of the bill and the insurance company pays 80 percent, but only after the insured has paid a co-pay and met the required deductible.

When a doctor orders tests from a diagnostic facility, they may be paid for by insurance, depending upon the specific test and the policy in force. If a particular policy does not cover lab tests, the bill must be paid by the patient.” []

‘Cash and Carry Healthcare’ is a proposed system in which patients would pay for outpatient doctor office visits in full at the time of the visit by cash, check or credit card eliminating the need for billing for office visits and carry their prescriptions, dispensed medications, healthcare appliances and accessories from the office. Payment by an insurance company acting as a middle man or co-payer for doctor services rendered would be eliminated.

The charge for the office visit would be determined by each specialized and non-specialized doctor based on the time with each patient and the procedures necessitated.

For example, if a doctor did not have to bill an insurance company, pay an insurance clerk, pay a billing company, comply with unnecessary insurance company credentialing procedures for the Doctor to be in the insurance companies networks, receive reimbursement based on rankings, comply with unnecessary regulations imposed by the government, use mandated electronic billing, be overly insured for malpractice and other costly requirements, the doctor could reduce the cost of an office visit significantly.

If insurance company and government Doctor requirements are eliminated, Doctors could offer office visits for ½ the current going office visit rate if they wanted in order to be competitive i.e. $50 for 15 minute office visit and $100 for 30 minute visit and prorated accordingly, or even less.

Additionally, Doctors should be incentivized to care for the indigent by enabling Doctors, with appropriate documentation, to deduct the donation of their office visit charge off their income taxes, which should be included with tax reform.

Doctors could elect to accept Medicare and Medicaid, if they wanted to, for payment, but Doctors would need an expensive billing system. Medicare and Medicaid would be optional.

Less expensive medical insurance for hospitalization, laboratory tests and x-rays would be customized for individuals. Family insurance plans for catastrophes, hospitalizations, emergency department visits, surgery, broken bones, x-rays, scans, laboratory tests, obstetrics, etc. could be likewise customized.

Doctors should be encouraged to dispense free and paid medicines, appliances, other accessories and write prescriptions for reasonably priced medicines. Previously effective reasonably priced medications should be reinstated in pharmacies by medical associations’ and organizations’ request i.e. American Medical Association, American Diabetes Association, American Academy of Pediatrics etc.

“Cash and carry was a policy requested by US President Franklin Delano Roosevelt at a special session of the United States Congress on September 21, 1939, subsequent to the outbreak of war in Europe. It replaced the Neutrality Acts of 1936. The revision allowed the sale of materiel to belligerents, as long as the recipients arranged for the transport using their own ships and paid immediately in cash, assuming all risk in transportation. However, the sale of war materials was not allowed.

“Though ‘Cash and Carry’ concepts had been introduced in the Neutrality Act of 1936, it only pertained to materials that could not be used in war efforts, which allowed them to aid warring countries. Originally presented to Congress by Senator Key Pittman (D-NV) earlier in 1939, the bill was designed to replace the Neutrality Act of 1937, which had lapsed in May 1939.[1]The bill had been defeated repeatedly by the Senate and the House on more than one occasion as Isolationists feared that passing the bill would draw the US into the conflict in Europe. However, President Roosevelt felt that further help was needed in Europe after Germany invaded Poland in September 1939. The bill passed in late October, gaining approval from the House on November 5, 1939.[2] The President gave his signature the same day.

“The purpose of this policy was to maintain neutrality between the United States and European countries while giving aid to Britain by allowing them to buy non war materials. Various policies, such as the Neutrality Acts of 1935, 1936, and 1937, forbade selling implements of war or lending money to belligerent countries under any terms. The U.S. economy was rebounding at this time, following the Great Depression, but there was still a need for industrial manufacturing jobs. The cash and carry program helped to solve this issue and in turn Great Britain benefited from the purchase goods.

“This program also prevented US businesses interests backing the success or failure of any warring nation. Because of the conclusion of the Nye Committee, which asserted that United States involvement in World War I was driven by private interests from arms manufacturers, many Americans believed that investment in a belligerent would eventually lead to American participation in war.

“The ‘cash and carry’ legislation enacted in 1939 effectively ended the arms embargo that had been in place since the Neutrality Act of 1936. It paved the way for Lend-Lease.

1. Brinkley, Dougals; Rubel, David (2003). World War II: The Axis Assault, 1939-1940. USA: MacMillan. pp. 99–106.
2. Divine, Robert (1969). Roosevelt and World War II. Baltimore, MD, USA: Johns Hopkins University Press. pp. 5–48

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