(08-20-2009 09:28 PM)Owl 69/70/75 Wrote:  

(08-19-2009 05:25 PM)Owl 69/70/75 Wrote:  At the end of the day, either you throw so many resources at health care that nobody ever goes wanting (and I think it's clear that we can't afford that), or you need some means to allocate scarce resources among those in need. There are basically two allocation methods--you go first if you pay more, or you go first based on some scheme established by fiat. Where the second is used, there has to be a "death panel" somewhere to make the decisions. If you know another way, then out with it, but so far I've not heard one.

Given a choice between pay-go or a death panel, I choose pay-go. At least with pay-go I can make the decision to forego something else to get health care, and when the actual user is on the hook for part of the cost, more effective control over costs results. I simply think pay-go is the fairer and more democratic alternative, given those two to choose from.

JAAO, or others who support any of the Obamacare forms.

Please read the above and tell me where I am wrong. This is why I believe that the democrat proposals, any of them on the table right now, will inevitably lead to deteriorating care and death panels.

Probably my last post on this subject; I’ll try and answer substantively. Keep in mind that I also would prefer something like the French system to what is being proposed. I just don’t think it’s feasible right now for reasons I’ve already mentioned. I think that these reforms are better than doing nothing for now, where as my understanding is that you think it’s worse than doing nothing.

Re: “death panels” can we agree to call it rationing? (Most “Death Panel” talk is actually about end of life counseling anyway.)

I think there is rationing now, it’s just done by insurance companies and on the basis of income (approximately), since a lot of employers don’t offer insurance and people often can’t afford the coverage they’d like. (Which also leads to more costs later due to poor preventative care.) I don’t think most doctors would disagree that insurance companies are rationing care currently.

My basic belief is this: if a 40 year old janitor and 40 year old corporate lawyer both have cancer, they both deserve the same level of treatment. But if they both want their wives to get boob jobs, and the lawyer can afford it and the janitor can’t, that doesn’t concern me. Something like Lasik can go in pay go too. Of course, it’s the middle ground between the two where the line is harder to draw. If we do end up having to make tough decisions about rationing, I prefer a medical professionals making it based on medical reasons than insurance company bean counters. Do I think a public option, for example, would be free of bean counters? No, but I’m a lot less uncomfortable with it than with insurance companies out for their own profit.

You use terms like “choose” and “decision” referring to pay-go, but there’s no choosing and no decisions for many, if not most Americans; they simply don’t have the money and/or are locked into whatever their employer offers. That’s why I’m less inclined to consider it “fairer and more democratic”. I’m OK with some things being pay-go, which is why we are at least able to agree that we like the French system. I like the fact that basic and catastrophic care is covered for everyone through redistributive taxation (which is why I think the Republicans would never endorse it) and you like that you can buy your way into better care. And I even accept that having that ‘top up’ option may have some trickle down effect on the overall quality of care in France.

I guess my last point is that I’m not sure why you think you wouldn’t be able to purchase a gold plated plan if you wanted and had the money. I think the odds are 2-1 that there will be no public option in whatever passes, so we’ll still have most people covered with private plans. Companies can still get the fancy plans for VPs if they want.

It just seems to me a lot of the criticisms of the reforms are making no distinction between Obamacare and single-payer and the British NHS. I just don’t see a situation here where people wouldn’t be able to buy the gold-plating if they wanted it.

Anyway, like I said, probably my last post on this, lot of stuff going on on the home front, so in allocating the scarce resource that is my free time, The Quad probably isn’t going to make the cut for a while. Hopefully, I’m taking my leave on a civil and constructive note…even if you think I’m dead wrong. Last word is yours.

(08-20-2009 06:15 PM)Rick Gerlach Wrote:  

(08-20-2009 05:09 PM)Ranger Wrote:  

(08-20-2009 05:06 PM)OptimisticOwl Wrote:  

(08-20-2009 02:36 PM)Ranger Wrote:  

(08-20-2009 09:28 AM)OptimisticOwl Wrote:  

(08-19-2009 04:41 PM)JustAnotherAustinOwl Wrote:  You want to talk about people that are scared? I have a cousin with a pre-existing condition who can’t get health insurance, and she’s not even 30 yet. She’s considered leaving the country to one that won’t treat her like complete @#$%. Another family we know is facing bankruptcy because they have a sick child who needs special care. They are, sorry - were, a middle class family with health insurance but the company went under and they have to pay COBRA, which is more than they can handle. My wife and her friends have been doing bake sales and charity auctions for them to keep them from going under. Why do we need to treat people like that in the wealthiest nation on earth?

Well, JAAO, I also have a pre-existing condition (more than one, actually) and am uninsurable. I turned to the Texas High Risk Healthpool and subscribed to a high deductible policy. The benefit to that is that the insurance has negotiated lower rates for procedures. I am leaving in about 15 minutes for yet another test(i might have yet another pre-existing condition) and I have been told the negotiated cost is $397. I am guessing the basic charge before negotiation would be $1200-1500. So even though I paid insurance costs plus over $7000 out of pocket last year, it was worth it for me. Tell your cousin to look into it as an alternative. Unfortunately, when I reach medicare age, the THRP will not cover me, so I will have no choice but to take the government option, just at a time when Obama is talking about cutbacks to help fund the coverage for his plan. And if I try to find out how that would affect me, I am just mean-spirited, unamerican, gun-toting, undereducated...

Owl 69's statements about fiat are spot on. Decisions will have to be made. How and who are the questions. A good example is the current system for organ transplants. There is a limited supply of livers. So when one comes available, a decision must be made - does it go to the 64 year-old diabetic or the 25 year-old single mom? Or if you like,, does it go to someone like me or to someone like your cousin? You don't want people with money getting to the head of the line, so i guess if I had seniority on the waiting list it would be OK with you if i went ahead of your cousin. So should it just be seniority that decides who gets scarce resources? Seniority = waiting lines.

Obamacare is not the Nirvana of healthcare, if anything it is the anything-but-what-we-have-now version, and as the election shows that is a bad basis to make choices. The administration wanted these bills SIGNED and in effect by now. No debate, no discussion, no tranparency. They wanted it rushed through, they failed, and now when people want to know what what they say, they either don't know, won't tell, or tell us to shut up. I want to know. Nothing wrong with that. It's not unAmerican to want to know.

Do you really believe that the priority for rationing will not be affected by political donations or support for the party then in power??

No, I don't believe that.

Hmmm. I think you will be surprised.

I think because you both had a negative (not/no) in your statements, what Optimistic was saying was that he did believe that rationing WOULD be (or at least COULD be) impacted by the whether or not you had the right connections. (and that he did not believe it would NOT be impacted, etc)

He's right. Let's take an example of a health plan that purported to treat all people the same, regardless of their station in life - the Soviet Union's healthcare. Of course the party members got better everything than the average Ivan, and the higher they were, the better they got. Supposeldly egalitarian plans are never truly egalitarian. That is why the President and Congress don't want to be on the same plan as they propose for the country - a question from the rude that they keep dodging.

(08-21-2009 03:38 PM)OptimisticOwl Wrote:  

(08-20-2009 06:15 PM)Rick Gerlach Wrote:  

(08-20-2009 05:09 PM)Ranger Wrote:  

(08-20-2009 05:06 PM)OptimisticOwl Wrote:  

(08-20-2009 02:36 PM)Ranger Wrote:  

(08-20-2009 09:28 AM)OptimisticOwl Wrote:  

(08-19-2009 04:41 PM)JustAnotherAustinOwl Wrote:  You want to talk about people that are scared? I have a cousin with a pre-existing condition who can’t get health insurance, and she’s not even 30 yet. She’s considered leaving the country to one that won’t treat her like complete @#$%. Another family we know is facing bankruptcy because they have a sick child who needs special care. They are, sorry - were, a middle class family with health insurance but the company went under and they have to pay COBRA, which is more than they can handle. My wife and her friends have been doing bake sales and charity auctions for them to keep them from going under. Why do we need to treat people like that in the wealthiest nation on earth?

Well, JAAO, I also have a pre-existing condition (more than one, actually) and am uninsurable. I turned to the Texas High Risk Healthpool and subscribed to a high deductible policy. The benefit to that is that the insurance has negotiated lower rates for procedures. I am leaving in about 15 minutes for yet another test(i might have yet another pre-existing condition) and I have been told the negotiated cost is $397. I am guessing the basic charge before negotiation would be $1200-1500. So even though I paid insurance costs plus over $7000 out of pocket last year, it was worth it for me. Tell your cousin to look into it as an alternative. Unfortunately, when I reach medicare age, the THRP will not cover me, so I will have no choice but to take the government option, just at a time when Obama is talking about cutbacks to help fund the coverage for his plan. And if I try to find out how that would affect me, I am just mean-spirited, unamerican, gun-toting, undereducated...

Owl 69's statements about fiat are spot on. Decisions will have to be made. How and who are the questions. A good example is the current system for organ transplants. There is a limited supply of livers. So when one comes available, a decision must be made - does it go to the 64 year-old diabetic or the 25 year-old single mom? Or if you like,, does it go to someone like me or to someone like your cousin? You don't want people with money getting to the head of the line, so i guess if I had seniority on the waiting list it would be OK with you if i went ahead of your cousin. So should it just be seniority that decides who gets scarce resources? Seniority = waiting lines.

Obamacare is not the Nirvana of healthcare, if anything it is the anything-but-what-we-have-now version, and as the election shows that is a bad basis to make choices. The administration wanted these bills SIGNED and in effect by now. No debate, no discussion, no tranparency. They wanted it rushed through, they failed, and now when people want to know what what they say, they either don't know, won't tell, or tell us to shut up. I want to know. Nothing wrong with that. It's not unAmerican to want to know.

Do you really believe that the priority for rationing will not be affected by political donations or support for the party then in power??

No, I don't believe that.

Hmmm. I think you will be surprised.

I think because you both had a negative (not/no) in your statements, what Optimistic was saying was that he did believe that rationing WOULD be (or at least COULD be) impacted by the whether or not you had the right connections. (and that he did not believe it would NOT be impacted, etc)

He's right. Let's take an example of a health plan that purported to treat all people the same, regardless of their station in life - the Soviet Union's healthcare. Of course the party members got better everything than the average Ivan, and the higher they were, the better they got. Supposeldly egalitarian plans are never truly egalitarian. That is why the President and Congress don't want to be on the same plan as they propose for the country - a question from the rude that they keep dodging.

Actually, some congresspersons have agreed to accept Obamacare. That is one reason why I grudgingly respect Ohio Senator Sherrod Brown, although do I not agree with him on policy. I understand when he was elected to Congress, he refused to accept the gold plated health care that Congress gets. Far too many congresspersons want us to eat what they cook, but they do not want to have to eat it themselves.

Not that I don't have anything better to do, but I went looking at Obama's campaign position sheets from last year. Actually, a lot of the broad brushes he talks about in there are actually in this plan. However, there are 2 big things that are missing from this, which I recall being stuff that were at least brought up on the stump as the kind of change he was bringing.

1. Catastrophic insurance coverage, to avoid the bankruptcy it brings (#1 cause of bankruptcy, as they say in the position paper)
2. Everyone will have insurance benefits as good as what Congress gets

Unfortunately, both of those promises cost a lot. Probably why they're not in there, but they were key talking points for beating up on the other side and talking about why Obama's plan was what you should support, if my memory serves me right.

I haven't been able to find enough records about what was discussed through the debates on health care. I will say this (though my memory usually isn't that good) - I don't recall much time being spent on it, and it was largely on platitudes/talking points on both sides. It sure wasn't a substantive comparison.

(08-21-2009 04:11 PM)gsloth Wrote:  2. Everyone will have insurance benefits as good as what Congress gets

Why not do a form of redistribution, and bring their benefits down to everyone else's?

(08-21-2009 03:25 PM)JustAnotherAustinOwl Wrote:  Probably my last post on this subject; I’ll try and answer substantively. Keep in mind that I also would prefer something like the French system to what is being proposed. I just don’t think it’s feasible right now for reasons I’ve already mentioned. I think that these reforms are better than doing nothing for now, where as my understanding is that you think it’s worse than doing nothing.

What I don't understand about your position is this. The democrats have the presidency, and overwhelming majority in the house, and a filibuster-proof majority in the senate, and it's somehow the republicans' fault that this isn't getting done? Not that I'm a fan of the republicans, but I do find your effort to shift blame as partisanship to the ridiculous degree.

There is one reason why this isn't getting done. Enough constituents have had the good sense to speak out about what is really a terrible idea (or collection of ideas), and enough congressmen have overcome the instructions of their party bosses and listened, that we are finally getting some sense into the process. Are there organized groups? Yes, on both sides. But they are hardly the main portion of the movement, at least not on the anti-Obamacare side. I would note that in all the photos I've seen, the opponents of Obamacare have been carrying hand-lettered signs, and the proponents have been carrying obviously preprinted ones. And as far as guns and swastikas and mobs and all those allegations, I simply haven't seen it; not to say that there hasn't been an isolated incident or two, but nothing to justify the hyperbole and hysteria voiced by Pelosi and the like. If you're actually seeing something different (as opposed to hearing someone speak words describing something different) then I would like to know where and when and how you are seeing it.

Quote:Re: “death panels” can we agree to call it rationing?

Sorry, but I really cannot agree to that. I think use of the term "death panels" in this context is far more accurate than the hyperbolic characterizations of the towm hall protesters by Obama, Pelosi, Reid, et al. As you point out below, rationing is what we have now. I'm seriously afraid that what we would evolve to is something far more perverse and evil. This is one major objection I have to the left's mantra. It's always greedy profit-seeking capitalists that are the root of all problems, and turning things over to altruistic government agencies is always the solution. I've spent most of my adult life working with one government agency or another, and the next altruistic government bureaucrat I meet will make the total equal to one. There are short-term abuses in the capitalist system, but in reality no capitalist enterprise remains profitable for long without providing a quality product or service at a reasonable price. The profit motive will see to that, except when the miscreants can pay their lobbyists enough to get the government to cover their tracks. Enron was a bunch of crooks, but their misdeeds caught up with them pretty quickly. There are government bureaucrats who have been at least as dishonest as the Enron gang, and have been getting away with it for 40 or 50 years or more. I categorically reject the notion that moving any function from the private sector to a government agency will necessarily improve the efficiency or the effectiveness, or even the honesty, with which such function is performed.

Quote:I think there is rationing now, it’s just done by insurance companies and on the basis of income (approximately), since a lot of employers don’t offer insurance and people often can’t afford the coverage they’d like.

We can agree here. Yes, there is rationing being done now, and rationing will continue in any system where we don't authorize an unlimited budget (and aren't prepared to see that unlimited budget exceeded). We do need to get insurance away from the employment model. That's one thing I like about France (although in actuality most employers provide supplemental insurance).

Quote:My basic belief is this: if a 40 year old janitor and 40 year old corporate lawyer both have cancer, they both deserve the same level of treatment. But if they both want their wives to get boob jobs, and the lawyer can afford it and the janitor can’t, that doesn’t concern me.

That sounds good in theory, but think it through. Do you want to make sure that both 40 year olds receive adequate treatment? The problem with that is that we can't afford to give everyone adequate treatment for everything. That is part of our problem now, we are pretty much giving everybody everything, and that is one reason why costs are out of control. Those on insurance get it paid by insurance, with little out of pocket. Those without insurance show up at the emergency room and get it for "free" as the costs are passed along to the rest of us.

Would a situation where neither got treatment be preferable to one where one did and one didn't? I think not, but I guess you would favor this since they would both be getting the same. This is how single-payer and single-provider systems control costs, so "death panels" is not inappropriate.

That leaves the situation where resources dictate that one can be treated and the other cannot, and the question is how to determine which one does and which one doesn't. Whatever we do is going to suck for somebody. If it's a single-payer system, that's pretty much game/set/match for whoever loses. If it's a free market system, or even a socialized system with adequate opt-outs, the loser may still have some options. That to me is much fairer and more democratic.

Quote:Of course, it’s the middle ground between the two where the line is harder to draw. If we do end up having to make tough decisions about rationing, I prefer a medical professionals making it based on medical reasons than insurance company bean counters. Do I think a public option, for example, would be free of bean counters? No, but I’m a lot less uncomfortable with it than with insurance companies out for their own profit.

I always prefer to have medical decisions made by doctors (and patients) than by bean-counters. I think a big problem with our system is that patients aren't involved in the decision-making. One key to getting the docs to buy off in France was the understaning that the doctor-patient relationship is where decisions would be made. I see no reason to believe that any government bureaucracy would be anything but an orgy of bean-counters. I think our fundamental difference is that you are less comfortable with profit-seeking insurance company bean counters than with power-seeking government bean counters, and I am just the opposite. If you can show me a situation where government bean counters have done a better job than private sector bean counters, then I'd be more willing to consider your position.

Quote:You use terms like “choose” and “decision” referring to pay-go, but there’s no choosing and no decisions for many, if not most Americans; they simply don’t have the money and/or are locked into whatever their employer offers. That’s why I’m less inclined to consider it “fairer and more democratic”. I’m OK with some things being pay-go, which is why we are at least able to agree that we like the French system. I like the fact that basic and catastrophic care is covered for everyone through redistributive taxation (which is why I think the Republicans would never endorse it) and you like that you can buy your way into better care. And I even accept that having that ‘top up’ option may have some trickle down effect on the overall quality of care in France.

There are more choices for more Americans today than there would be under Obamacare in any of its versions. If my insurance company turns me down, I can mortgage my house or do something to get the money, if it's that important (that seems to be what happens in UK, by the way; I am always amazed at how many Brits I meet who have mortgaged their homes to pay for private health care when NHS failed them).

You have touched on what I think is a major problem with US health care--the employer link. You end up with relatively few buyers (the employer HR departments), all with pretty much the same objectives, dealing with relatively few sellers (those insurance companies big enough to take on the large group plans), under heavy government regulation (which provides serious barriers to entry by new and innovative competitors). In many states, a "one size fits all" plan is mandated by law, and any efforts to innovate would be illegal. In France, the "free" plan is "one size fits all," leaving countless opportunities to innovate in designing supplemental plans. IIRC there are supplemental plans that emphasize wholistic and homeopathic medicine, among others. That means that what France has is much closer to a free market than the highly regulated monopoly/monopsony situation here.

Quote:I guess my last point is that I’m not sure why you think you wouldn’t be able to purchase a gold plated plan if you wanted and had the money.

You can't do that in Canada (although they are moving back in the direction of opening up more and more to it, because they have realized that without it their system is a failure), and that seems to be the ultimate model in the eyes of Obama.

Quote:It just seems to me a lot of the criticisms of the reforms are making no distinction between Obamacare and single-payer and the British NHS. I just don’t see a situation here where people wouldn’t be able to buy the gold-plating if they wanted it.

Actually, with the NHS you can get gold-plated private insurance, at a gold-plated price. It's Canda where you can't, and Canada seems to be the model Obama wants to emulate more than UK. He has repeatedly said that he favors single-payer (which Canada is) and I've never heard him mention single-provider (which UK is). I would prefer UK to Canada, but I see no reason to stick around if either gets imposed on us.

I do realize that none of the current bills takes us all the way to where Canada is. But that has been Obama's stated goal, on multiple occasions, and he has also stated on multiple occasions that he expects a gradual transition over 15 to 20 years. That being the case, if these proposals aren't part of that gradual transition, then why does Obama support them? If they are, then why should I support them?

If we are in a 15 to 20 year transition to something like what Canada has today, I certainly hope that I don't live that long. If I do, then I plan to live elsewhere.

(08-21-2009 03:25 PM)JustAnotherAustinOwl Wrote:  My basic belief is this: if a 40 year old janitor and 40 year old corporate lawyer both have cancer, they both deserve the same level of treatment.

I note that you use the same age, but you didn't compare a 12 year old school boy to a 52 year old bartender, etc, etc.

In theory, that sounds fair. But the key is can we afford to give everyone equal treatment? Maybe we can, for now, if costs are at 'x'. Maybe not, but let's say we can, if we raise taxes (as must be done to accomplish this).

But if prices escalate, or if a greater percentage of people get cancer, the only way we then can continue to provide everyone with the same level of service is either:

a. continue to raise taxes
b. lower the level of treatment

Considering the increase in population, and the increase in life expectancy, it's a pretty good bet that the amount of money required to provide 'equal service' will continue to go up, just as it has to date.

So the 'death panels' that people worry about are not necessarily something that will be in place in 2010 or 2011. But when the day comes that the public plan runs out of money, severe rationing is almost inevitable.

The fact that your example was equal as long as age was equal is potentially a big concern. That's not real equality.

Death panels? Not tomorrow.

But again, the people who set up Social Security (and who have mismanaged it) didn't originally worry that it would ever go broke. Once in a place, although we've known for awhile that it will go broke, nothing has really been done to address it.

(although the thought of taxing those benefits, which ought to be tax free in ANY event, if you've had the ability and the good sense to provide yourself with additional retirement doesn't seem to bother Democrats either).

While Social Security has been helpful, public programs run by bureacrats, do not have a great history, and seem to inevitably fall to mismanagement or poor initial forethought and planning.

Actually, Rick, you forgot one other possibility to continue to provide everyone the same level of service: lower the cost of procedures. Malpractice insurance is obviously a big component, and I'm sure there are others. I don't see a whole lot of that in the current proposal (kind of obvious when you have a CBO estimate of a 10-year net cost savings of approximately negative $1 trillion). Too many entrenched interests are lobbying to keep their preferred status or minimize a negative change from the status quo (and I'm not just referring to the lawyers here; pharmaceuticals, hospitals, etc. are all calling in their chits).

And I state it that way in part for the obvious shock value. I do wonder, though - if everyone is covered in some way, shape or form, assuming nothing else changes, what direction would the general cost of services go? On the plus side, providers are less likely to have to write off procedures due to non-payment of most of the cost (depending on how deductibles work), so you would think their gross revenue would increase. However, now the providers don't have a pool of customers that might not be covered that they can slap with the high charges while giving in to the insurance companies on their lower allowable charges, meaning tightening on that revenue side of the equation.

I'm not sure anyone can know the answer to that right now, but it's definitely an interesting question (IMO).

Rating providers is now being done. Each provider is being scored on quality of care given as well as cost effectiveness to provide that care, a process developed in the private sector. For example, one provider may use a certain type of laproscopic equipment to remove a gall bladder that costs $300 and another may use equipment that costs $3000. Obviously, the outcome is the same for both, gall bladder removed, so the first provider has accomplished the goal in 1/10th the cost. The next evaluation would be to ensure that the quality of care is the same and that unexpected complications are not higher in the first case by using cheaper instruments thus driving up the cost of delivery to the system overall for that procedure. Providers and hospitals will be reimbursed for providing better care more efficiently. In the above senario, provider a gets paid mor than providor B and the surgery center gets to keep more of the global reimbursement. Government programs can't seem to figure this out. Medicare is full of inequities that drive up the cost without increasing quality. For example, a dermatologist will get paid 4x the amount a primary care physician will get paid to do the same procedure. The cost cutting measure is to deny claims from a PCP for skin cancer removal and the only way a PCP will get paid is to downgrade the claim to a skin lesion removal which pays 1/4 the amount. The quality of care may or may not be improved by utilizing the dermatologist but in doing so the cost of care has quadrupled. It is assumed that if you can devise a system that contains the cost of care without decreasing quality then you have found the right system. Unfortunately, I don't see a government run program incentivising efficiency or quality. The private sector at least rewards quality and efficiency. The only problem is that a percentage of the resources is allocated to administrative costs and profits which reduces money available for patient care. A government plan tries to avoid any motive for profit but actually accomplishes the same problem, siphoning off resources, by creating inequitable reimbursements and services by administrators consolidating their power.

(08-21-2009 10:23 PM)ruowls Wrote:  Rating providers is now being done. Each provider is being scored on quality of care given as well as cost effectiveness to provide that care, a process developed in the private sector. For example, one provider may use a certain type of laproscopic equipment to remove a gall bladder that costs $300 and another may use equipment that costs $3000. Obviously, the outcome is the same for both, gall bladder removed, so the first provider has accomplished the goal in 1/10th the cost. The next evaluation would be to ensure that the quality of care is the same and that unexpected complications are not higher in the first case by using cheaper instruments thus driving up the cost of delivery to the system overall for that procedure. Providers and hospitals will be reimbursed for providing better care more efficiently. In the above senario, provider a gets paid mor than providor B and the surgery center gets to keep more of the global reimbursement. Government programs can't seem to figure this out. Medicare is full of inequities that drive up the cost without increasing quality. For example, a dermatologist will get paid 4x the amount a primary care physician will get paid to do the same procedure. The cost cutting measure is to deny claims from a PCP for skin cancer removal and the only way a PCP will get paid is to downgrade the claim to a skin lesion removal which pays 1/4 the amount. The quality of care may or may not be improved by utilizing the dermatologist but in doing so the cost of care has quadrupled. It is assumed that if you can devise a system that contains the cost of care without decreasing quality then you have found the right system. Unfortunately, I don't see a government run program incentivising efficiency or quality. The private sector at least rewards quality and efficiency. The only problem is that a percentage of the resources is allocated to administrative costs and profits which reduces money available for patient care. A government plan tries to avoid any motive for profit but actually accomplishes the same problem, siphoning off resources, by creating inequitable reimbursements and services by administrators consolidating their power.

I'm not sure that I understand exactly what you are talking about, at least when it comes to reimbursement for individual procedures by Medicare. In the example that you gave , regarding removing a skin lesion, if the primary care doc and the dermatologist do EXACTLY the same procedure (shave biopsy, excision, complex closure, etc) and document that in the record and code it properly, they will receive exactly the same reimbursement from Medicare. Every practicing physician who is a Medicare provider uses the same coding manual (reimbursement varies from region to region).

Medicare reimbursement is blind to whatever training or specialty the physician has when he submits the charge. If you are a neurosurgeon and want to perform and charge for a hysterectomy (and can document the procedure) Medicare will reimburse you for the procedure. Credentialing for procedures is carried out on a local level (hospital prvileges, surgical center privileges, insurance plans etc). These credentialling procedures have become very important from a medico-legal and hospital accreditation standpoint. They are very complete and very detailed. And physicians are subjected to these "re-credentialling" processes every other year, or so.

So, from a practical standpoint, it's pretty unlikely that a neurosurgeon would perform and submit a charge for a hysterectomy. But, if he initially trained as a gynecologist, then re-trained as a neuro surgeon, I suppose the hospital could be forced to grant him the privileges that he initially trained for. Very unlikely. In your example of the skin lesion, it is far more likely that a Primary care provider could have attained the skills to remove a skin lesion during his training. Most of these guys rotate through surgery during their trainig.

Bottom line..Medicare doesn't care what your traing or declared specialty is. If you do the procedure, document it and code it properly, Medicare will reimburse you, the same as your colleague down the street who may have completely different training (or no training at all).

(08-21-2009 09:35 PM)gsloth Wrote:  Actually, Rick, you forgot one other possibility to continue to provide everyone the same level of service: lower the cost of procedures. Malpractice insurance is obviously a big component, and I'm sure there are others. I don't see a whole lot of that in the current proposal (kind of obvious when you have a CBO estimate of a 10-year net cost savings of approximately negative $1 trillion). Too many entrenched interests are lobbying to keep their preferred status or minimize a negative change from the status quo (and I'm not just referring to the lawyers here; pharmaceuticals, hospitals, etc. are all calling in their chits).

And I state it that way in part for the obvious shock value. I do wonder, though - if everyone is covered in some way, shape or form, assuming nothing else changes, what direction would the general cost of services go? On the plus side, providers are less likely to have to write off procedures due to non-payment of most of the cost (depending on how deductibles work), so you would think their gross revenue would increase. However, now the providers don't have a pool of customers that might not be covered that they can slap with the high charges while giving in to the insurance companies on their lower allowable charges, meaning tightening on that revenue side of the equation.

I'm not sure anyone can know the answer to that right now, but it's definitely an interesting question (IMO).

Good point, and I did think about it, I just don't think that's an area the Democrats will ever go. Lawsuits are, after all, one way to make big, bad rich people pay for mistakes or other injustices. And lawyers have to take their percentage out of the system as well, and that in turn helps fund our elections and PACs. (I acknowledge there are plenty of good lawyers and reasonable lawsuits . . . it's just that the system has gotten out of whack in the past).

Even if we do have tort reform, I think that population growth and increased longevity will eventually take its toll on any system, whether it's social security or universal health care. It just might take a little longer.

(08-22-2009 09:29 AM)greyowl72 Wrote:  

(08-21-2009 10:23 PM)ruowls Wrote:  Rating providers is now being done. Each provider is being scored on quality of care given as well as cost effectiveness to provide that care, a process developed in the private sector. For example, one provider may use a certain type of laproscopic equipment to remove a gall bladder that costs $300 and another may use equipment that costs $3000. Obviously, the outcome is the same for both, gall bladder removed, so the first provider has accomplished the goal in 1/10th the cost. The next evaluation would be to ensure that the quality of care is the same and that unexpected complications are not higher in the first case by using cheaper instruments thus driving up the cost of delivery to the system overall for that procedure. Providers and hospitals will be reimbursed for providing better care more efficiently. In the above senario, provider a gets paid mor than providor B and the surgery center gets to keep more of the global reimbursement. Government programs can't seem to figure this out. Medicare is full of inequities that drive up the cost without increasing quality. For example, a dermatologist will get paid 4x the amount a primary care physician will get paid to do the same procedure. The cost cutting measure is to deny claims from a PCP for skin cancer removal and the only way a PCP will get paid is to downgrade the claim to a skin lesion removal which pays 1/4 the amount. The quality of care may or may not be improved by utilizing the dermatologist but in doing so the cost of care has quadrupled. It is assumed that if you can devise a system that contains the cost of care without decreasing quality then you have found the right system. Unfortunately, I don't see a government run program incentivising efficiency or quality. The private sector at least rewards quality and efficiency. The only problem is that a percentage of the resources is allocated to administrative costs and profits which reduces money available for patient care. A government plan tries to avoid any motive for profit but actually accomplishes the same problem, siphoning off resources, by creating inequitable reimbursements and services by administrators consolidating their power.

I'm not sure that I understand exactly what you are talking about, at least when it comes to reimbursement for individual procedures by Medicare. In the example that you gave , regarding removing a skin lesion, if the primary care doc and the dermatologist do EXACTLY the same procedure (shave biopsy, excision, complex closure, etc) and document that in the record and code it properly, they will receive exactly the same reimbursement from Medicare. Every practicing physician who is a Medicare provider uses the same coding manual (reimbursement varies from region to region).

Medicare reimbursement is blind to whatever training or specialty the physician has when he submits the charge. If you are a neurosurgeon and want to perform and charge for a hysterectomy (and can document the procedure) Medicare will reimburse you for the procedure. Credentialing for procedures is carried out on a local level (hospital prvileges, surgical center privileges, insurance plans etc). These credentialling procedures have become very important from a medico-legal and hospital accreditation standpoint. They are very complete and very detailed. And physicians are subjected to these "re-credentialling" processes every other year, or so.

So, from a practical standpoint, it's pretty unlikely that a neurosurgeon would perform and submit a charge for a hysterectomy. But, if he initially trained as a gynecologist, then re-trained as a neuro surgeon, I suppose the hospital could be forced to grant him the privileges that he initially trained for. Very unlikely. In your example of the skin lesion, it is far more likely that a Primary care provider could have attained the skills to remove a skin lesion during his training. Most of these guys rotate through surgery during their trainig.

Bottom line..Medicare doesn't care what your traing or declared specialty is. If you do the procedure, document it and code it properly, Medicare will reimburse you, the same as your colleague down the street who may have completely different training (or no training at all).

That was my point. The system is not perfect. You do the exact same procedure and get paid less. You use the same CPT codes and ICD codes. You document the same. Most of the time this is not the case but you do get anomalies in the system. Each provider also must have an NPI number to submit a claim to Medicare which has primary specialty and other provider specific info linked to it. It is possible to deny a CPT code when that code is linked with a NPI number. For the majority of the time, you are correct in that any provider that submits a CPT code, the reimbursement is the same. Regional reimbursement is also a joke. In the 90's with the proliferation of Medicare HMOs, residents of certain counties were getting free limo rides to appointments because reimbursements to the carriers by Medicare were 3x that of rural counties. This is despite the fact that premiums were equal for both groups. The rural areas were in essence subsidizing the urban group. Also, that type of system discourages allocation of providers to rural areas. Credentialing has nothing to do with reimbursements. It is a tool used by hospitals to document competency and quality. Hospitals must now document OPPE for each provider with recredentialing occurring on 2 year cycles. I just so happened to turn mine in last week. Each specialty has a core competency and any procedures you do beyond your core you must show competency within the last 2 years. In your scenario, a neurosurgeon can only get credentialed to do hysterectomies if they have done the minimum number to prove competency in the last 2 years. If they were trained as a gynecologist but have not done one in the last 2 years, you don't get credentialed to do the procedure.

I agree with you, totally, RU. The neurosurgeon/gynecologist scenario was a bit of hyperbole. I realize that on a local level it would be unlikely that the neurosurgeon would get privileges to do the hysterectomy, because it would be unusual if he kept doing that procedure after he trained in neurosurgery. He couldn't continue to show competence in that area.
I guess my point was that Medicare doesn't care about the provider's training. Basically, reimbursement is the same for whoever submits the correct and documented charges.

(08-23-2009 05:15 PM)greyowl72 Wrote:  I agree with you, totally, RU. The neurosurgeon/gynecologist scenario was a bit of hyperbole. I realize that on a local level it would be unlikely that the neurosurgeon would get privileges to do the hysterectomy, because it would be unusual if he kept doing that procedure after he trained in neurosurgery. He couldn't continue to show competence in that area.
I guess my point was that Medicare doesn't care about the provider's training. Basically, reimbursement is the same for whoever submits the correct and documented charges.

I agree with you as well. However, there are some reimbursement inequities that occur. No system will ever be perfect but sometimes good intentions are poorly thought out. And sometimes, backdoor deals are made with certain interests in mind. The skin biopsy was one example. I actually had to go through a 2 day course about 10 years ago which allowed me to "act" as a dermatologist due to a lack of derm care within an IPA group with private insurance contracts. In this case, only 10% of primary care providers could submit the "specialist" codes for reimbursement. It didn't effect Medicare charges or payments however. Another inequity used to be Synvisc or Hyalgan intraarticular injections for arthritis. Medicare would only reimburse orthopedists or rheumatologists for the procedure. That did change after a few years and now even I can get paid for injecting these medications. The funny thing was that during that restriction of those 2 drugs, I could inject a steroid intraarticularly and get paid the same as an orthopedist and rheumatologist. The reason was to restrict utilization because a steroid cost $20 and the Synvisc was $1500. The rationale was that the specialists were the trained providers that understood the proper use of an expensive drug. Another example of special interest politics is preparticipation physicals for high school sports. Podiatrists and chiropractors may provide this service and charge for it in some states despite the fact that they have been deemed unable to do admission History and Physicals or presurgical H&Ps within ANY hospital or surgical center. Another example is optometrists now being able to bill and prescribe certain treatments and medications relating to the eye. Since diabetes can lead to retinopathy, it is possible for optometrists to provide diabetic care including diabetic medications. They do have to certify that they have completed additional CME to prescribe but their diabetic training is somewhat limited. My point on all of this is that some people in a position to make policy will make the decision for the good of their power base and not necessarily the best choice for cost effective high quality patient care.

http://www.theatlantic.com/doc/200909/health-care

Interesting read. Would be interested in comments.

(08-24-2009 06:47 AM)Owl 69/70/75 Wrote:  http://www.theatlantic.com/doc/200909/health-care

Interesting read. Would be interested in comments.

I think he does a great job in outlining the problems of the current system, and I think he succeeds extremely well at highlighting the internal tension between insurance-based funding and market-based funding. If society wants to fund through insurance, we have to recognize that the system will lack true market pressures and efficiency will suffer. If society wants to forego insurance, efficiency will be improved but individuals will bear much greater risk than at present.

I don't think he does a particularly compelling job with any of his proposed solutions, though. Take his discussion on page 2 around the absurdity of insurance-based funding for scheduled routine care:

"Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance... "
It's a great point. From this perspective, clearly all routine care should be pay-go.
But wait. Routine care provides major benefits that are likely to lower total health care expenditures in the long term. An ulcer, if left untreated, can turn into emergency surgery and a catastrophic health care event. The author, to his credit, recognizes this on page 6:
"Some experts worry that requiring people to pay directly for routine care would cause some to put off regular checkups. So here’s a solution: the government could provide vouchers to all Americans for a free checkup every two years. If everyone participated, the annual cost would be about $30 billion—a small fraction of the government’s current spending on care."

So his proposal would replace the replace the absurd bureaucracy, red tape, and distorted market signals of insurance-based financing of routine care with government-based financing of routine care? I don't see how that addresses any of the author's well-posed concerns. Unfortunately, I don't see anything better-- collective payment for individual routine care (either via private insurance or government, there's hardly a difference), while problematic, provides benefits that outweight its problems.

So I agree with nearly all of his issues with the current system, but I don't share his faith that blowing it up will lead to better outcomes. The example I've given above is the only specific implementational detail I see in his article, and it's clearly a cul-de-sac much more than a way forward.

I don't agree, I just thought it was an interesting read.

I think your analysis points up one big problem with this debate--it is easy to find problems with the current system (and it's pretty easy to see how the author's personal experience biases his slant on things), but it's a lot more difficult to figure out something that would acually SOLVE any of the problems.

I do agree with characterizing three levels of health care:
1. Basic,
2. Elective, and
3. Catastrophic.

I prefer the French approach to dealing with those three levels to his approach. They use universal, private sector health insurance for basic care, government umbrella coverage for truly catastrophic situations, and allow a variety of free-market approaches to elective care--self funding, private insurance, employer provided insurance (spending accounts would also work well here, but I'm not sure whether they have them).

I can justify universal primary care becuase that's the level at which there are some serious societal benefits to keeping everyone free of things like swine flu or smallpox. There are doc-in-the-boxes selling prepaid primary care packages for $87/month; something like that is affordable across the board. I think we can achieve significant savings in the primary care area by maximizing the use of nurse practitioners and other paraprofessionals. Docs are bailing out of family practice these days; let them concentrate on specialties.

I think the government umbrella works well for truly catastrophic situations, because the governement is the one entity with sufficient resources not to be bankrupted by a catastrophe, and because taking that burden off the insurance companies gives them freedom to become much more creative in structuring elective care solutions.

The more like a free market we can make elective care, the more LASIX-type success stories we are going to see.

(08-24-2009 12:41 PM)Owl 69/70/75 Wrote:  I don't agree, I just thought it was an interesting read.

I think your analysis points up one big problem with this debate--it is easy to find problems with the current system (and it's pretty easy to see how the author's personal experience biases his slant on things), but it's a lot more difficult to figure out something that would acually SOLVE any of the problems.

I do agree with characterizing three levels of health care:
1. Basic,
2. Elective, and
3. Catastrophic.

I prefer the French approach to dealing with those three levels to his approach. They use universal, private sector health insurance for basic care, government umbrella coverage for truly catastrophic situations, and allow a variety of free-market approaches to elective care--self funding, private insurance, employer provided insurance (spending accounts would also work well here, but I'm not sure whether they have them).

I can justify universal primary care becuase that's the level at which there are some serious societal benefits to keeping everyone free of things like swine flu or smallpox. There are doc-in-the-boxes selling prepaid primary care packages for $87/month; something like that is affordable across the board. I think we can achieve significant savings in the primary care area by maximizing the use of nurse practitioners and other paraprofessionals. Docs are bailing out of family practice these days; let them concentrate on specialties.

I think the government umbrella works well for truly catastrophic situations, because the governement is the one entity with sufficient resources not to be bankrupted by a catastrophe, and because taking that burden off the insurance companies gives them freedom to become much more creative in structuring elective care solutions.

The more like a free market we can make elective care, the more LASIX-type success stories we are going to see.

Ouch, that one hurt.

That is one of the problems with US medicine. We have subspecialized and general care is harder to obtain. FPs have left because in a system driven by reimbursement for procedures, it is difficult to pay for cerebral management. There is no doubt I'm worth a lot but most don't share my point of view. That's the difference between a paraprofessional and a physician. The physician will usually reach an adventageous decision with less costly input. In other words, we guess right with fewer tests. There is a place for specialist and the procedures they do. There is also a place for quality management by physicians. Nurse paractitioners and paraprofessionals are a good way to augment an FP but they shouldn't replace them. You will probably see a system which integrates general care within regional pods and groups of physicians and extended care providers while more specialized care is available affiliated referal centers.

RU,

Not meant to attack or disparage you at all. My point was that docs are already abandoning family practice for higher-priced specialties, and paraprofessionals may be one way to bridge the gap. I spent several months at a time at sea with 300 other people in a high-risk environment, with nothing more than a navy corpsman, sometimes 1000 miles to the closest doc, and we got through just fine.

I think your pod concept would work with one doc supervising several paraprofessionals.