I would wager that the average age was lower and fitness standards were higher than the general population. Also helps if helicopters are available to lift people in serious need of care to safety.

No offense taken. It was all in jest. I know some extended providers who are better than many physicians, myself excluded of course. Providers need to coordinate care better and work together better. About 2 weeks ago, I had a patient that had a recurrent cyst in his eyelid. We tried the conservative treatments which didn't work. We referred him to an ophthamologist to remove the chalazion. He went to the appointment and the ophthamologist started listing the things that we had done as things he could try. He told them he had done all of those things already and the ophalmologist reached the conclusion that it should be removed. Then he scheduled him to come back and see the eyelid specialist in the group because he didn't do eyelids anymore and that he only did cataracts. Obviously, the patient had a wasted visit and incurred extra charges because an ophthamologist only fixed a certain part of the eye. The real reason was to probably optimize reimbursement for the ophthamology group that had to pay for their new surgery center and suite at Bulldog Stadium for the upcoming football season. If you had a cohesive group of doctors that work together to provide the care, then the triage is done by the PCP and the specialty procedure is done by the specialist without any extra steps. In a pure capitalistic system, providers are competitors with each other and collabaration could suffer. That is why you need some mechanism to align incentives for a group of providers for a given population base. Statistically, you can estimate the medical needs of the patient base and match the appropriate providers to deliver the care. However, there will always be decepencies as you can't predict precisely the utilization. Catastrophic illness can be referred into a tertiary center with more specialized care. We have to get away from all our restrictive transfer laws and integrate the system on a larger scale. The preventative and routine illness care can be handled on a local level and you have a heirarchy of increasingly complex care established for each region. Therefore, the referal centers would in essence be a "specialty" hospital. One referal center would handle all the more complex cases of cardiac care while another would handle all the complex cancer cases and so on and so on. It would cut down on duplicate services for more complex care but would still maintain increasing complex medical care for a local region. It would be a system where input is on the local level and care is given at the appropriate facility within that region. The problem would be cost controls without competing institutions but without duplication of services by competing institutions, the charges could be linked to actual cost of care and not artificially driven up. Technology could be controlled as each region would have the power to buy on a large scale and can obtain proposals from various companies to obtain the neccessary equipment for the region. There would be competion to provide this service which would help control the cost here. Any thoughts?

(08-25-2009 10:46 AM)Fiftysix Fortytwo Wrote:  I would wager that the average age was lower and fitness standards were higher than the general population. Also helps if helicopters are available to lift people in serious need of care to safety.

No helicopters back then (though that would probably be the case today), and we were frequently beyond helo range of any assistance. Age and fitness probably true, but that probably does no more than to offset the risk factors of being at sea.

RU, that sounds like the joke I had at the Fondren orthopedic center when I had my second knee surgery - I had to go back because only the left knee doctor was in; the right knee doctor was drumming up business on the slopes in Vail!

RU - not to pick on you, but you raise an intriguing idea on pooling doctors. But what's to prevent almost a cartel-like level of collusion on these things, like what appears to be going on at least in Las Vegas? Then again, as the article shows, what's to prevent it from happening now, especially with the level of collusion that appears to be going on? Crazy stuff, and probably more common that we realize, though this one appears especially brazen.

That's what happens when you introduce a lawyer into the mix. Under current laws, if a physician group or delivery system controls more than 80% of a service area, it will be broken up due to undo influence on the local market. As to Las Vegas, it is notorious for shady medical care. Most of the internet prescription sites were based in Las Vegas and there was a huge crackdown on these establishments a few years ago. In the example you gave, the doctors were in essence getting kickbacks from the lawyers as well as getting reimbursement from auto, workers comp, and other accident insurance. The incentive is to provide more services but also bolster the lawyer's case for a larger settlement. In a nutshell, insurance fraud. An example of a regional multispecialty approach would be something like the Mayo Clinic, Cleveland Clinic Foundation, or Sansum Clinic in Santa Barbara, CA. You can have a national body monitoring utilization within each region and if certain procedures fall out due to over utilization you investigate. You have an expected utilization for care and it would pop up pretty quickly if you have major outliers. Furthermore, there is a huge database for best practice models and evidence based medicine.

This Las Vagas situation is nothing new, unfortunately. The media has reported on this type of fraud for years in many places, including Florida, New York ..and Texas.

Thinking about this, we can set up 6 super regions with 5 subordinate regions in which to pool resources. Let's call the super regions the Pacific, Atlantic Coast, East, Southeast, Big Lakes and Big Plains regions. They will get the majority of funding. However, if one of the subordinate regions is able to post a performance index score better than the lowest ranking super region score in any given year, they will get an extra distribution payment for that fiscal year.

(08-27-2009 06:26 PM)ruowls Wrote:  Let's call the super regions the Pacific, Atlantic Coast, East, Southeast, Big Lakes and Big Plains regions.

You've got me curious, so I have to ask: "Big" but not "Great"?
Perhaps we could add a region for the desert southwest and called it the Large Canyon region.

(08-27-2009 09:25 PM)georgewebb Wrote:  

(08-27-2009 06:26 PM)ruowls Wrote:  Let's call the super regions the Pacific, Atlantic Coast, East, Southeast, Big Lakes and Big Plains regions.

You've got me curious, so I have to ask: "Big" but not "Great"?
Perhaps we could add a region for the desert southwest and called it the Large Canyon region.

With the intellect of some of the athletes at the schools in those areas, you have to avoid those 5 letter words and stick with 4 or less.

From the American Issues Project, via Facebook:

This has been my expectation all along, that the rest of the world will pull out of this, and we won't because of the "stimulus."

Remember the Days When Our Economy Was in Better Shape Than France's?

Today at 4:23am

Earlier this month, Christina D. Romer, chairwoman of the Council of Economic Advisers gave a speech in which she said that the President's economic stimulus plan was "absolutely" working. She anchored her claim on the fact the the decline in GDP, which had been falling faster than Wile E. coyote holding onto an anvil, had slowed to mere 1 percent in the second quarter this year.

To be fair, the GDP decline the quarter before that was 6.4 percent, which means that we've gone from a freefall that would have left a Chicxulub-sized crater to one that will only leave a small dent when we finally hit bottom. However, there is evidence that we didn't need the stimulus bill at all and that Romer's claim was completely ridiculous.

This editorial at Forbes does the heavy lifting on the latter part of the previous sentence. The authors note that only a small portion of the stimulus funds have actually been spent, even on the projects that the Democrats were claiming would heal the economy the fastest -- government projects like road repairs, building improvements, and other "shovel ready" projects. They also throw down a few charts to show that our economy is that our economy is still hurting very badly in areas such as consumer spending and investment and employment.

As for the evidence that we didn't need the stimulus bill at all, we have only to look outside our own borders. Mark Steyn surveyed the world economic situation and found that most of the major economies of the world are actually growing right now, albeit slowly. The only ones that are still shrinking are the ones that threw obscene amounts of taxpayer money at their recession.

Meanwhile, in Brazil, India, China, Japan and much of Continental Europe the recession has ended. In the second quarter this year, both the French and German economies grew by 0.3 percent, while the U.S. economy shrank by 1 percent. How can that be? Unlike America, France and Germany had no government stimulus worth speaking of, the Germans declining to go the Obama route on the quaint grounds that they couldn't afford it. They did not invest in the critical signage-in-front-of-holes-in-the-road sector. And yet their recession has gone away. Of the world's biggest economies, only the U.S., Britain and Italy are still contracting.

It's not unreasonable to wonder if the stimulus plan is the reason our economy is still shrinking. After all, loading a trillion dollars or so of debt onto our backs and the backs of our children and grandchildren is bound to have a chilling effect on private investment. Of course, there's also the very real likelihood that the President and his Democratic allies will make good on their threat to tax the rich until there's nothing left but a few dried husks in nice suits, which is not exactly a great incentive to create more wealth.

At this point, I think we can safely say that the current administration's stimulus plan was not a very good idea at all. The only real question is what sort of long-term damage it will do.

There is a silver lining, though. Since most of the money hasn't actually been spent, Congress can always repeal the bill. It won't save all our money, but it'll save quite a lot.

(08-21-2009 09:35 PM)gsloth Wrote:  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).

Howard Dean admitted there is no "Tort Reform" in the Health Care Bill because "they didn't want to fight the Trial Lawyers."

I think its more accurate to say they didn't want to piss off one of the Democrat Party's biggest contributors.

(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.

Like any Civil Service Administrative position, there could be an element of corruption.

Most likely it isn't overt discrimination against a Political Opponent by denial of Health Care--- it will be "give me $10,000 and I'll approve your procedure or put you on the top of the waiting list."

(08-28-2009 05:58 AM)Owl 69/70/75 Wrote:  Meanwhile, in Brazil, India, China, Japan and much of Continental Europe the recession has ended. In the second quarter this year, both the French and German economies grew by 0.3 percent, while the U.S. economy shrank by 1 percent. How can that be? Unlike America, France and Germany had no government stimulus worth speaking of, the Germans declining to go the Obama route on the quaint grounds that they couldn't afford it. They did not invest in the critical signage-in-front-of-holes-in-the-road sector. And yet their recession has gone away. Of the world's biggest economies, only the U.S., Britain and Italy are still contracting.

Someone correct me if I'm wrong, but both did pass substantive stimulus packages and faced plenty of criticism for extending deficits further in doing so.

Germany's stimulus package, expanded to the GDP of the US, works out to $451 billion, while France's comes in around $234 billion.

(08-28-2009 11:19 AM)At Ease Wrote:  

(08-28-2009 05:58 AM)Owl 69/70/75 Wrote:  Meanwhile, in Brazil, India, China, Japan and much of Continental Europe the recession has ended. In the second quarter this year, both the French and German economies grew by 0.3 percent, while the U.S. economy shrank by 1 percent. How can that be? Unlike America, France and Germany had no government stimulus worth speaking of, the Germans declining to go the Obama route on the quaint grounds that they couldn't afford it. They did not invest in the critical signage-in-front-of-holes-in-the-road sector. And yet their recession has gone away.

Someone correct me if I'm wrong, but both did pass substantive stimulus packages and faced plenty of criticism for extending deficits further in doing so.
Germany's stimulus package, expanded to the GDP of the US, works out to $451 billion, while France's comes in around $234 billion.

Bear in mind that those are the author's words, not mine.

I think what he was getting at was that the French and German stimulus efforts were much smaller than our "stimulus" plan. Of course, there was also an EU stimulus plan which presumably had some impact on all EU members. I do come up with considerably smaller equivalents for France and Germany, but couldn't find data for the EU part, so I didn't consider that in my calculations.

On a qualitative basis, it does appear that the French and German plans were aimed more at things that would really stimulate the economy and less at rewarding political favors that ours was.

Angela Merkel, for one, did lecture Obama pretty strongly about his "stimuls" plan going too far.

HERE is MY problem with government run health care... and the complaints/solutions.

For the moment, I'm going to avoid talking about special situations... because while I don't dismiss them in any way... they are the exception rather than the rule... and if we can solve the problems of 85% of Americans, we can charge that 85% a few extra dollars and slove the problems for the tougher cases...


In simplest terms... Insurance, no matter WHO runs it... is about collecting premiums that are equal to or greater than what you pay out for services... plus the cost of administering those services. Certainly, insurance companies spend a fair amount of time and money fighting claims... and balance that with the cost of "paying" if you lose in court or whatever... PLUS losing customers if your program is run poorly. In this country... Doctors should ALWAYS be able to charge more if they offer a superior level of care... and people should ALWAYS be able to purchase a better level of care if they are willing to pay for it themselves. Anything that doesn't allow that is socialism and has no place in this country.

Insurance companies have an incentive to keep administrative costs low. They have an incentive to keep expenses down. They ARE incented to have income as high as they can get away with, but the free market system keeps them from being able to gouge people. Though they certainly measure things like the cost of paying claims versus the cost of fighting them, and paying only if they lose... at least there is a way to fight them and punish them for doing wrong through the courts and through the government. Who does that for complaints against the government? Sure, you can vote out your representative... but you can't vote out the Medicare Administation Board.

In something run by the government... there is ZERO incentive to keep overhead down. In fact, they are incented to keep overhead high and NEVER cut administrative costs. Only in government do we have the "if I don't spend it, i lose it" mentality... You can't tell me the government doesn't deny claims that all of us think should be paid... and if they are wrong, whom do you sue?? The answer is nobody... and while they don't mind suing insurance companies, lawyers don't like to sue the government.

Without endorsing the specifics of his plan, or claiming this is exactly what he envisioned... I REALLY liked some of what I heard of McCain's Healthcare proposal... and I wish we'd adopt something like the following:

We should establish some level of basic healthcare for everyone. There are already some pretty reasonable HMO type health-care coverages you can buy for around $500/month/Family. No, not a perfect plan... but something that covered an awful lot of what most people need. People could make some choices between more coverage and a higher co-pay or deductible, or less coverage and lower out-of pocket costs. It could be funded by what we currently pay for Medicare/Medicaid... PLUS rather than force employers to offer and administer a healthcare plan... we could simply 'tax" them an equivalent amount for this basic plan. Employers at the larger companies, or those who have competitive fields where benefits are an important part of the equation could then offer ad-on insurance policies with the companies or the individuals paying only the difference between the basic and the "golden" plan.

The government would only need to administer the premium collections and monitor the policies offered... maybe offer seminars on the choices... PEOPLE would be free to choose from the variety of policies offered. The government could oversee complaints and even take insurers out of the mix if they fail to provide the services they agreed to offer. Talk about oversight... If you fail in your duties, we can take millions of policy holders away from you and give them to your competition. Insurance is about spreading risks. You want as big a pie as possible. Losing ALL of your customers because you fight them too hard is a big disincentive... and having high ratings that attracts more people.. ESPECIALLY if you are SO much better than that last company that when they get kicked out of the plan, you get ALL of their customers??

Only problem is... I am quite certain that when this happens... we'll do that moronic thing that government always does...

Turn this into an experiment in social engineering... because we didn't learn anything from the mortgage mess

We are the world's largest debtor nation. No economy in history has long maintained a leading position in the economies of the world as a perpetual debtor. Therefore we must reverse the trend and become a creditor nation again. If we do not, over time all our wealth will simply drain away and we will be reduced to banana republic status.

There are two sources of our debt, one well known, one less so:
1. Trillion dollar a year federal budget deficit (well known)
2. Trillion dollar a year foreign trade deficit (less well known)

This is made worse because
1. Americans have one of the lowest savings rates in the world, so a disproportionate part of both deficits has to be financed overseas
2. The overseas places that we go to finance our debt include countries who are connected to terrorism (Arab world) or whose interests across the board simply do not agree with ourse (China).

Basically, we are dying unless we can reverse the deficits.

The trade deficit can be reversed by either reducing imports or increasing exports. What attention has been given to this issue has focused strictly on protectionist tactics to limit imports. The problem is that we can only go so low with imports, and protectionist tactics harm export sales, historically more so than they decrease imports. The threshhold on imports is set largely by imported oil, which makes up half the net trade deficit. We need to reduce oil imports. Unfortunately, the Obama energy "plan" will inevitably result in our importing more oil in 2015 than we do today. That may be a shocking conclusion, but I've run the numbers and that's where they lead.

As far as increasing exports, there is nothing on the table that will help that. Ross Perot had some good ideas in this regard (and a bad one about NAFTA, but that was more because of the impact on his own wallet than on concern for Americans' well-being). If China can pay factory workers a dollar a day and blow off environmental protection, then we have to meet them on those terms (which I would oppose), or come up with advantages elsewhere (which I favor), or lose. As Perot correctly stated, the best ways to improve exports would be lower taxes, streamlined and focused regulations, and an approach to environmental issues based on results (actually improving the environment) rather than process (see how many lawyers and consultants and bureaucrats we can keep employed).

The government deficit can obviously be reversed by either raising taxes or cutting government spending. If we raise taxes, then we shoot our export sales in the foot. What we need is to balance the books through a combination of reduced spending and a more rational tax structure. I would favor what I'll call the 15-15-15 approach that most eastern Europe countries have taken a they move from communism to capitalism. 15% consumption tax, 15% tax on busines profits, 15% payroll tax (like current social security with no upper income limit), no personal income tax, and a version of the Boortz-Linder fair tax prefund (at a 30% rate) would raise sufficient revnues to balance the pre-bailout, pre-stimulus budget. Do that and cut spending back to that level, primarily by offsetting any new programs by cancelling old and outdated ones (as Reagan said, there is nothing on earth closer to eternal life than a federal bureaucracy).

That's my view. I think the US is doomed without a major change in direction that I don't see coming. Where am I wrong?

(10-07-2009 05:40 PM)Owl 69/70/75 Wrote:  That's my view. I think the US is doomed without a major change in direction that I don't see coming. Where am I wrong?

Your choice of those shoes with that shirt

Not to worry: even if this Administration does not advance the U.S. economy, it is certainly making great strides in foreign policy. "For the last several years", as the President frequently likes to preface things, the U.S. has suffered from the fact that tyrants dislike us and democracies disrespect us. Fortunately, Obama is well on his way to ensuring that the reverse is true.

(10-08-2009 11:03 AM)georgewebb Wrote:  Not to worry: even if this Administration does not advance the U.S. economy, it is certainly making great strides in foreign policy. "For the last several years", as the President frequently likes to preface things, the U.S. has suffered from the fact that tyrants dislike us and democracies disrespect us. Fortunately, Obama is well on his way to ensuring that the reverse is true.

you mean that tyrants disrespect us and democracies dislike us?

Unfortunately, I'm not convinced that is true yet (assuming you mean that they start liking us again). Apparently Russia and Great Britain were pretty upset at the way he handled the Iran announcement... His personal popularity is somewhat based upon the fact that he has a great face and can deliver a great speech, but most of them don't have a clue as to what he does.

If we're completely honest... while I'll agree 100% that Bush's policy of "going it alone" wasn't handled well at all... it REALLY wasn't much different than what we've done in the past or since... which is go it alone in terms of bearing the brunt of the expense and work, but under the control of some other entity. iirc, we provide 90% of the aid to Africa for AIDS and 70% of the humanitarian aide... and they hate us anyway. Somehow, it's OUR fault that their government steals the food we give them to feed the army that opresses them.

What we MUST admit is that having a common enemy is what keeps most of these people in power... and while Israel is a common enemy of the middle east, it doesn't attract sympathy from Africa. The US as a common enemy DOES. If the US is no longer "The Great Satan", then why can't we have McDonalds in Tehran and US movies in the theater?