RiceLad15
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RE: Mail-in voting
(08-15-2020 01:05 PM)Hambone10 Wrote: (08-15-2020 12:12 PM)RiceLad15 Wrote: I feel like that’s a good comparison, actually.
Payment to send a letter is the same, regardless of the density of delivery. So USPS makes more money if they can deliver 1,000 pieces of mail in a denser suburb in an hour than say 50 in a rural area in an hour.
So it’s also about volume of service in both instances - greater population density means more customers and more efficiencies in both instances.
Sure... if you assume that the delivery of most mail is as important as the delivery of healthcare. That's my point is that MOST mail isn't remotely important... and that that IS important is most often (in one way or another) funded by the government anyway.
Remove the subsidy for junk mail and keep it for government mail. If Junk mailers still want to deliver it to dense populations, that's fine... the post office can charge them a penny more, and reduce the need for government subsidy for prescriptions to BFE.
I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.
In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).
Quote: (08-15-2020 12:16 PM)RiceLad15 Wrote: My understanding is that USPS is also struggling due to some funding mandates imposed by Congress associated with retirement benefits.
Regardless, I think your argument makes sense, but isn’t realistic. There will need to be a significant transition period where two things happen: broadband is actually extended to all parts of America, and technology to use/access needs to equally penetrate those areas.
If we’re talking about whether we should be subsidizing the USPS in 20 years, then I can understand that position. But since we can’t convert all necessary aspects of USPS overnight, we must continue to effectively fund and operate it until a digital alternative is developed.
So, again, why not both?
I guess i wasn't clear about my 'more' comment.
I've suggested a way for the government to subsidize 'necessary deliveries'... without having to subsidize NON essential deliveries.... just to make sure that people in rural areas get daily delivery of their junk mail just like people in big cities.
As to the pensions, Revenues for all other 'delivery' services have doubled in the past 10 years or so, while USPS has remained flat. Revenues are not impacted by pensions and benefits.
But you DO bring up one of the problems with government sponsorship/co-opting of private enterprise. The company must play by government rules which other delivery services do not. We're not talking about general employment rules, but specific 'we work for the government' rules.
I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.
Quote: (08-15-2020 12:30 PM)RiceLad15 Wrote: It sounds less like Medicare makes this worse, and more like Medicare doesn’t address this problem. Or are you saying that, if Medicare reimbursed at the same rate in all areas, providers that currently operate on the city would relocate to rural areas?
Does Medicare keep private practices from opening and operating in rural areas?
Your comments here demonstrate to me that you don't understand what either of us are saying... which is why you don't see this as a medicare problem.
Let's start with this. Medicare sets the standards. Medicaid, Marketplace and Commercial all follow them. If they don't address it, then it basically doesn't get addressed.
That said, let me show you the simple math of RU's example... just as an example
Medicare pays a GP $100 to remove a skin lesion. They pay a specialist $200 for the same service. Because of the volumes, the GP can fill his day without that, and there is plenty of volume now for a specialist as well. LA county (like almost every urban center) is an expensive town, so they get a 25% positive adjustment... so they actually receive $125 and $250.
The rural county doesn't have a specialist... So on the surface, they pay a GP $100 to remove the lesion... however... because of the lower cost of living, they get a 25% 'hit'... and they only get $75. Now in hard to staff areas, they may bump them back up somewhat... but that requires big studies. 'Cost of living' is a much more readily available and trusted measure than is 'hard to recruit/staff'. They might get a 10% bump or more likely, they get something like a one-time bonus... most often funded through medicare/the state, not medicaid/the feds.
$250 vs $75. That's how they make it worse.
Now throw this in.....
You're an MD... There is more to living in Fresno vs LA than simply cost of living.... and Fresno isn't a tiny place. Culture, peers, diversity, beaches, arts... easy opportunity to participate in CME or an opportunity to develop a specialty practice... the availability of qualified staff and local training for them... I mean, the list of differentials is very long...
Do they stop them from opening? Of course not. That question is meaningless. The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills? Every small town doesn't have a Vialula. More often they have Nancy Lee's.
The reason this matters is because they demand the same quality out of both. If they don't deliver the quality, the reimbursement goes down.... which defeats the whole purpose of the location adjustments, unless they also pay to recruit nurses and staff and fund prettier/better hospitals etc etc.
It's like g5 vs p5. Yes, it's harder to win in p5, but you're easily arguably better off being a losing team in p5 than a winner in g5.
I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.
The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").
It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.
We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.
Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.
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