The healthcare market does vary across the country. However, we physicians do not determine our reimbursement regardless of what we bill the insurance companies. They pay us a set rate for a particular operation, irrespective of our charges. Interestingly, the bar is set by Medicare. Every insurance company reimburses us at a percentage of Medicare. That percentage can be negotiated, but usually only by a large medical group. The guys in small groups like myself typically are left with the base contract of 90% of Medicare, “take it or leave it.”

1. The insurance companies are freed from responsibility for making decisions that are essentially medical in nature. However, ERISA created a significant barrier to employee action against insurance and managed care companies regulating the provision of services to employees.

2. Insurance companies driven by profit motive seek ways to limit payouts which have led to the scandals in providing coverage.

3. Individuals have no bargaining power with the insurance companies over the cost and composition of policies when bought on an individual basis.

4. The sheer multiplicity of insurance options and the difficulty in determining future medical needs on the part of the individual purchaser makes it difficult to really assess the desirability of policies.

5. Cherry picking has become the rule of the day with the primary purpose of the insurers to pick out those with the least likely need for medical services. As these individuals age or develop chronic disease, the insurance companies quickly drop them as customers or steer them into policies that are either too expensive to maintain or provide insufficient coverage.

6. Employer provided insurance is going the same way as employees take on greater deductibles and co-pays as well as steered into HSA plans.

Isn’t it true, though, that there really isn’t a health care market? I mean, costs for operations vary all across the country, and if we could create more of a national marketplace for insurance, perhaps that competitiveness would drive down costs.

Costs for operations vary around the world. There’s a reason why Americans are increasingly traveling to India and Thailand for operations that cost a fraction of what they’d cost in the United States – including airfare.