I thank Dr. WhiteCoat for this provocative and thoughful post and recommend it for a good read!

I agree with the mantra “free=more” being false, and I think free medical care will turn into rationed care  and declined quality (already happening with mcd pts),i lie your suggestions however I dont think it will work.  My thoughts:

1) Insurance companies have a big stake in the process (along with Pharma), and strong influence ($$$) which extends beyond this administration into congress.  Insurance co’s don’t want to give up their control over profits  plus the power to control the money maker- MD’s.  We are not organized (sans unions) thus have little collective power against them.  Its a perfect  situation for them, however they would never allow their position being decentralized in any fashion.   I dont think they’re invested in cutting costs, but interested in protecting their profits.  Personally, I think they need to be MORE regulated, and not for profit, but that would never happen.

2) Patients dont want to pay (they might get organized enough to stop a concept like this, but thus far haven’t been organized enough to stop insurance companies impact on their care) thus elected officials would be very unpopular supporting it, and would fear risking taking that stance if they seek re-election

3) i like the idea of listing costs for procedures, for cost comparison, however it would mostly be applicable to upper-middle to upper class people who could chose in this scenario. They would have the means to do so, resources and ability to navigate through multiple hospital systems in different regions/countries to reach their goal (cheaper treatment).  I dont think all patients are educated consumers, I think thats more influenced by education and socio-economic background which will leave out a whole class of people.

4) The results of #3 would adversely affect hospitals in urban areas (where I am) treating poorer populations which tend to be medically more complex or chronically ill.  I would anticipate privately insured pts would increasingly leave the city for tx, and urban hospitals would primarily care for more complicated patients who were on medicare and medicaid (with terrible reimbursement rates).  I question if the actual cost of running all hospital operations to be equivalent between comparable institutions when procedure shopping (does a hospital in Manhattan versus Peoria have the same operational costs which I imagine to impact the procedure cost)?

5) offering consumers a “reward” of a 10% rebate cash would probably work, however in most other service professions, you do get what you pay for…. a comparative procedure at a lesser cost (A versus A) might yield a lesser quality one with higher risks,  but a cheaper procedure/treatment  (A versus B) which yields the same result might be an area that would produce effective savings

I  love the idea of a health care pre-payment set up (akin to a legal retainer, or DDM’s), which includes cutting out the MD from dealing with insurance companies (the BANE of my existence, an INCREDIBLE time consumer), though that is wishful thinking as well…

Efficiency amongst staff is another way to change cost, however that deserves an discussion of its own…

I  agree, if patients paid for their procedures they would be more selective when managing their care.

If we look at this arrangement with a systems perspective:  MDs are at the center of this debate, without us this entire system cannot work.  Even if PA’s and NP’s  take on more roles of MD’s, they cannot replace MD’s.  The training is not equivalent.  Period.  The power lies in MD’s taking a dramatic stance, setting limits to this increasingly tightened  situation in which we practice medicine.

That, however, will not happen until enough MD’s create a mass effect by collectively standing up and saying we cannot practice medicine appropriately and will cease to continue to do so.  I think we are approaching a boiling point, but are not there yet.