Interesting read on the GOP and health insurance

[The Cheesehusker, Trade Warrior]

From the NYT no less - makes some excellent points and observations

https://www.nytimes.com/2017/07/07/opinion/republicans-health-care-new-start.html

[Con Reeder, unhyphenated American]

On 2017-07-07, The Cheesehusker, Trade Warrior <iamtj...@gmail.com> wrote:
> From the NYT no less - makes some excellent points and observations
>
> https://www.nytimes.com/2017/07/07/opinion/republicans-health-care-new-start.html
>

That's Peter Suderman of Reason. No surprise. One of my charitable gifts
every year.

Still in all, it's pie in the sky. No one thinks a from-scratch bipartisan
health care reform can be achieved. The Democrats left wing is going nuts
for single-payer, they can't consider compromise.

--
"Laughter is inner jogging." -- Norman Cousins

[The Cheesehusker, Trade Warrior]

HEALTH CARE IS NOT HEALTH INSURANCE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

HEALTH INSURANCE IS NOT HEALTH CARE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

they're related, but they're NOT THE SAME THING

pardon - just needed to get that off my chest

[Con Reeder, unhyphenated American]

I agree. But since we are giving Medicaid to all comers, it has become
health care reform. I would love to see real health insurance, but
Obamacare killed that.

Would that I could have an HSA and a policy that only started paying
after I went $10,000 out of pocket. Combine that with rolling back most
regulations on starting health care providers, which would stimulate a
supply-side renaissance, we might get somewhere. But that would make
too much sense.

--
We should not be surprised to find the left concentrated in institutions
where ideas do not have to work in order to survive. -- Thomas Sowell

[tim.vanwa...@gmail.com]

If you want to open a private practice and don't want to take Medicare or Medicaid, the only regulation that is medical specific is having a license. A couple states make you have malpractice insurance. If you have employees, you will have to deal with OSHA, but their medical regulations are pretty common sense given the enormous risk to both the provider and patient and they've been generally drilled heavily into your head by the time you finish training.

If you want to take Medicare, sure you're gonna have lots of regulations to deal with. And you should. That's taxpayer money. And that certainly isn't easy, but there are plenty of resources to help with that.

Again, the giant enormous barrier to market entry is the training required. frankly, I'd like to know that the ER doc that I didn't have a chance to search about before they dragged by my MI suffering soul into the hospital is at least competent, so relaxing that would be insane. They could help this a lot by allowing mid level providers to do more, to open more slots in medical schools and training programs, and to import more well trained docs from abroad. But that is the profession, not the government that largely blocks those things.

I'd love to hear what elixir of regulatory reform would dramatically help the profession (other than Medicare, cause again, that's my money is like to know is at least moderately well spent).

[unclejr]

Who are you? ($1)

[The Cheesehusker, Trade Warrior]

On Friday, July 7, 2017 at 10:00:19 AM UTC-5, tim.vanwa...@gmail.com wrote:

> If you want to open a private practice and don't want to take Medicare or Medicaid, the only regulation that is medical specific is having a license. A couple states make you have malpractice insurance. If you have employees, you will have to deal with OSHA, but their medical regulations are pretty common sense given the enormous risk to both the provider and patient and they've been generally drilled heavily into your head by the time you finish training.

And this is pretty much the reason concierge medicine is growing each year - many docs love it - far less paperwork, more time w/ patients, etc

> If you want to take Medicare, sure you're gonna have lots of regulations to deal with. And you should. That's taxpayer money. And that certainly isn't easy, but there are plenty of resources to help with that.
>
> Again, the giant enormous barrier to market entry is the training required. frankly, I'd like to know that the ER doc that I didn't have a chance to search about before they dragged by my MI suffering soul into the hospital is at least competent, so relaxing that would be insane. They could help this a lot by allowing mid level providers to do more, to open more slots in medical schools and training programs, and to import more well trained docs from abroad. But that is the profession, not the government that largely blocks those things.

Correct - there should indeed be barriers to entry at the top - otoh, lessened restrictions at the bottom. We're seeing some loosening of regs (Of which state laws have effects) - and could use more

> I'd love to hear what elixir of regulatory reform would dramatically help the profession (other than Medicare, cause again, that's my money is like to know is at least moderately well spent).

Well, are you sure Medicare money *is* well spent? Is the quality of healthcare better than for healthcare provided via other means?

[tim.vanwa...@gmail.com]

The new burdensome regulations/payment models that everyone is complaining about, like MAPS, MIPS and CPC+ are specifically there to start ensuring the funds are well spent on quality, meaningful care. That's why they complain - no more anything goes with Medicare. The providers/system's total reimbursement is based upon the outcomes of their patients, so they get a certain reimbursement for services delivered and Payment for the care management of your patient population (which is variable based on your patient pool), but you would also get a performance based payment based on quality measures shown to drive down the total cost of care. However, they are largely blocked by Congress by really doing cost effectiveness regulations - and since insurance companies largely follow CMMS lead on this, that means a lot of our care provided is not as cost effective as it should be. That is a big reason why we spend twice as much on medical care in the U.S. than any other country. Too bad we're not getting the subsequent health improvement. for example, a drug or device manufacturing company now just has to show that their product is effective to be included in the standard of care and thus able to be reimbursed for. But it doesn't take enough account anything like DALY or QALY/$, so that new heartburn drug that costs 5x as much but is only 2% more effective and doesn't change the patient's quality of life is covered. Since the patient might bear the same cost no matter the bottom line to Medicare, they have no incentive to question the cost. Instead, we have this bizarre system where you can advertise to the patient, provide no context on how effective or costly that solution is, get the patient worked up about trying the drug 'cause it's new and thus must be better, and voila... out of control health care spending.

[Con Reeder, unhyphenated American]

On 2017-07-07, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
> If you want to open a private practice and don't want to take Medicare
> or Medicaid, the only regulation that is medical specific is having a
> license.

I am talking about hospitals and other provider facilities, not
individual practicioners.

> A couple states make you have malpractice insurance. If you have employees, you will have to deal with OSHA, but their medical regulations are pretty common sense given the enormous risk to both the provider and patient and they've been generally drilled heavily into your head by the time you finish training.
>
> If you want to take Medicare, sure you're gonna have lots of regulations to deal with. And you should. That's taxpayer money. And that certainly isn't easy, but there are plenty of resources to help with that.
>
> Again, the giant enormous barrier to market entry is the training required. frankly, I'd like to know that the ER doc that I didn't have a chance to search about before they dragged by my MI suffering soul into the hospital is at least competent, so relaxing that would be insane. They could help this a lot by allowing mid level providers to do more, to open more slots in medical schools and training programs, and to import more well trained docs from abroad. But that is the profession, not the government that largely blocks those things.
>
> I'd love to hear what elixir of regulatory reform would dramatically help the profession (other than Medicare, cause again, that's my money is like to know is at least moderately well spent).

Allowing doctor-owned hospitals. Removing all certificate of need
requirements. Broaden allowed care by DNP, NP, and PA. Allow visits
with video-linked diagnosticians. Reducing number of regs for introducing
new treatments. Etc, etc. All this varies by state, of course, but
Obamacare is like an anchor attached to it all.

--
Opportunity is missed by most people because it is dressed in
overalls and looks like work. -- Thomas Edison

[michael anderson]

On Friday, July 7, 2017 at 10:00:19 AM UTC-5, tim.vanwa...@gmail.com wrote:

> If you want to open a private practice and don't want to take Medicare or Medicaid, the only regulation that is medical specific is having a license.

huh? To get on any insurance panels, you're going to have to at least be board eligible. Which means completing an american/acgme residency training program. I'd say thats effectively a 'regulation'.

I guess theoretically someone with a medical license who only did a year or two of residency could use their medical license and see patients in a private outpatient(they are unlikely to get any hospital priv) practice, but how in the world would they get paid? I highly doubt that any cash/concierge patients would choose to go see someone who is not even board eligible.

You need to be board eligible to bill medicare as well. Medicaid is actually the one entity that a non-board eligible licensed physician could bill independently.

>
> Again, the giant enormous barrier to market entry is the training required. frankly, I'd like to know that the ER doc that I didn't have a chance to search about before they dragged by my MI suffering soul into the hospital is at least competent, so relaxing that would be insane. They could help this a lot by allowing mid level providers to do more, to open more slots in medical schools and training programs, and to import more well trained docs from abroad.

the # of acgme residency spots is already so large that 20% or more(I dont know the exact numbers since all these lesser quality DO schools are popping up and competing with imgs for slots) of all the acgme slots can be filled by international grads now.

>But that is the profession, not the government that largely blocks those >things.

well every state that I am aware of requires at least one year of residency training in an approved american/acgme program to be eligible for a state medical license, so thats a clear govt obstacle.

But the idea that a physician in india who practices in india should be able to come over and see patients in america without an acgme residency program is insane and ludicrous. I know plenty of board certified physicians in multiple specialties who did med school in another country and practiced medicine in another country for some time, and they would tell you that the idea they were ready to practice independently on day #1 of their internship/residency here in the states is crazy. In fact, it's usually the case that the intern on day #1 who went to an american med school is more 'ready to go' in internship than the IMG who has tons of experience in their own country. Some of it is cultural familiarity with our way of doing things here, but frankly a lot of it isn't....

>
> I'd love to hear what elixir of regulatory reform would dramatically help >the profession (other than Medicare, cause again, that's my money is like to >know is at least moderately well spent).

As someone who generates 60% or so of their income from medicare now(just because of the population I treat...I do mostly geriatric inpatient psychiatry in private practice), I can assert that medicare is very inefficient. The example I always give is that when I admit a Humana/blue cross/Anthem/etc pt, I know their will be a peer review at some point where I have to justify my reason to keep the patient and continue expensive inpatient treatment. If they are medicare? Carte blanche....(unfortunately for taxpayers). *Occasionally* they will come back and do an audit later...but those arent frequent.

[michael anderson]

On Friday, July 7, 2017 at 4:56:24 PM UTC-5, Con Reeder, unhyphenated American wrote:
> On 2017-07-07, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
> > If you want to open a private practice and don't want to take Medicare
> > or Medicaid, the only regulation that is medical specific is having a
> > license.
>
> I am talking about hospitals and other provider facilities, not
> individual practicioners.
>
> > A couple states make you have malpractice insurance. If you have employees, you will have to deal with OSHA, but their medical regulations are pretty common sense given the enormous risk to both the provider and patient and they've been generally drilled heavily into your head by the time you finish training.
> >
> > If you want to take Medicare, sure you're gonna have lots of regulations to deal with. And you should. That's taxpayer money. And that certainly isn't easy, but there are plenty of resources to help with that.
> >
> > Again, the giant enormous barrier to market entry is the training required. frankly, I'd like to know that the ER doc that I didn't have a chance to search about before they dragged by my MI suffering soul into the hospital is at least competent, so relaxing that would be insane. They could help this a lot by allowing mid level providers to do more, to open more slots in medical schools and training programs, and to import more well trained docs from abroad. But that is the profession, not the government that largely blocks those things.
> >
> > I'd love to hear what elixir of regulatory reform would dramatically help the profession (other than Medicare, cause again, that's my money is like to know is at least moderately well spent).
>
> Allowing doctor-owned hospitals. Removing all certificate of need
> requirements. Broaden allowed care by DNP, NP, and PA.

Don't a lot of people realize that this is not neccessarily more cost effective? Just because an NP/PA makes a fraction of what a physician might make doesn't always mean $ are saved in the end.
In most cases the dollars are just passed around a little differently....

[Con Reeder, unhyphenated American]

But it can be. I am not talking spare change here, I am talking
about systematically new health care vehicles.

> Just because an NP/PA makes a fraction of what a physician
> might make doesn't always mean $ are saved in the end. In most cases
> the dollars are just passed around a little differently....

As the system stands now. I want it all delivered in more innovative
ways, which might be possible if we stop doing the same old crap.

--
There's nothing sweeter than life nor more precious than time.
-- Barney

[tim.vanwa...@gmail.com]

More innovative ways is not about who you're paying, it's about how and what you're paying for. You can't control costs just by paying by procedure, just paying less for that procedure. We tried that and Congress keep delaying and delaying it because the industry flipped out. You have to move to models where you combine managed care with performance based payments rewarding the providers for meeting targeted outcomes for the health of the patient. Believe it or not, the most innovation in this is going on in the federal government with the experiments CMMI is doing right now. They have a major incentive to change the cost curve. The private sector, both on the payer and provider side have far less incentive (and in reality, disincentive) to do so under the current system.

[michael anderson]

On Saturday, July 8, 2017 at 1:17:53 AM UTC-5, tim.vanwa...@gmail.com wrote:
> More innovative ways is not about who you're paying, it's about how and what you're paying for. You can't control costs just by paying by procedure, just paying less for that procedure. We tried that and Congress keep delaying and delaying it because the industry flipped out. You have to move to models where you combine managed care with performance based payments rewarding the providers for meeting targeted outcomes for the health of the patient.

the problem with this is that in such a model providers have a strong incentive to self select those more likely to meet those outcomes. And I don't neccessarily mean avoiding the sickest patients....I mean avoiding the ones that(for a variety of factors, some of which may have to do to the nature of their disease state) are least likely to show improvement to meet those criteria. Thats not a good situation.

I actually think these other models are far more susceptible to provider abuse. In terms of being paid for work not really done.

Look, as long as I can remember(I'm 37) people have been saying "we've got to fix health care"..."what can we do"...."need reform"....blah blah blah. When I'm 60 we'll still be hearing the same stuff in slightly different forms. A more appropriate perspective is to sit back and say "things are all right". Are there always going to be problems? Sure, that's the nature of the beast. But I don't so much worry about what % of the gdp health care consumes and the trend there....we've got to spend our money on something after all, and as one sector of spending decreases another must rise(after all you've got to get to 100%)

I see tons and tons of providers lamenting how much better things used to be "20 or so years ago" from a satisfaction and compensation standpoint, but I'm old enough to remember(not as a provider but I was aware of the news) 20 years ago, and a lot of the same complaints were present. Both from providers and patients and advocacy groups.

We've got a good system....could it be better? Increasing reimbursements to providers would be a start I think, but just because things aren't perfect now doesn't mean all is woe. A positive outlook about our current system is the best approach imo.

[J. Hugh Sullivan]

On Fri, 7 Jul 2017 08:00:16 -0700 (PDT), tim.vanwa...@gmail.com
wrote:

>If you want to open a private practice and don't want to take Medicare or M=
>edicaid, the only regulation that is medical specific is having a license. =

In some areas doctors are forming groups and one of them is always
available to make house calls. They don't even have an office - just a
call service. I think there is an annual fee to avoid a billing
process or cash. The patient files his own insurance claims. I don't
know how that works for doctors charging more than Medicare
allowables.

Some doctors are reducing days worked to become more selective in the
patients they accept - my GP is one. He has reduced me to 1 physical
er year but I can get an appointment on the day I call (so far)

Either way resonsible people pay the bills for the irresponsible ones.
The difference is that we seldom have to sit in the bleachers or end
zone seats with the latter ones.

Hugh

---
This email has been checked for viruses by AVG.
http://www.avg.com

[Con Reeder, unhyphenated American]

On 2017-07-08, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
> More innovative ways is not about who you're paying, it's about how
> and what you're paying for. You can't control costs just by paying by
> procedure, just paying less for that procedure. We tried that and
> Congress keep delaying and delaying it because the industry flipped
> out. You have to move to models where you combine managed care with
> performance based payments rewarding the providers for meeting
> targeted outcomes for the health of the patient.

There you go with that centralized control crap again.

> Believe it or not,
> the most innovation in this is going on in the federal government with
> the experiments CMMI is doing right now. They have a major incentive
> to change the cost curve.

They do? Pray tell, what is that? They can't get fired, and they
have taxpayer-funded benefits that are much greater than anyone
in the public sector. Sounds like their incentive is to cover their
ass and not get fired, not take risks to try and improve costs.

> The private sector, both on the payer and
> provider side have far less incentive (and in reality, disincentive)
> to do so under the current system.

Horsehockey. It isn't "the private sector" you count on to try
and lower costs -- it is the consumer. And they'll do it if you
give them the chance to make decisions based on their perception of
care quality and price.

You apparently believe centralized control will lower costs
better than the patients making choices based on price signals. History
says you are deluded beyond belief due to the information problem.

Obamacare made one-size-fits-all choices for coverage, and prices rose
dramatically. Not surprising except to people who are ignorant in
economics. But Democrats profess surprise, and want to double
down with single-payer.

--
Fast, reliable, cheap. Pick two and we'll talk.
`

[tim.vanwa...@gmail.com]

Connie, this isn't about centralized control or Obamacare. This isn't some textbook or theoretical economic paradigm. Healthcare isn't like buying a television, so outside of getting the government completely out of the picture, which, if that is your answer shows that you're delusional, ...

Never mind, there is no point in arguing with someone that just reflectively just falls back on a worldview and thinks that is the answer to every contingency. There's nothing rare about that, it happens on both sides, but those of us actually in the game have realities that we have to deal with.

[Con Reeder, unhyphenated American]

On 2017-07-10, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
> Connie, this isn't about centralized control or Obamacare. This isn't
> some textbook or theoretical economic paradigm. Healthcare isn't like
> buying a television, so outside of getting the government completely
> out of the picture, which, if that is your answer shows that you're
> delusional, ...

The inevitable straw man. Because I suggest that consumers can make good
health care choices given the proper amount of information, you say "get
government completely out of health care".

> Never mind, there is no point in arguing with someone that just
> reflectively just falls back on a worldview and thinks that is the
> answer to every contingency.

I hope that doesn't describe me nearly as well as it describes you.

> There's nothing rare about that, it happens on both sides, but those
> of us actually in the game have realities that we have to deal with.

And my guess is that skin in the game gives one an agenda.

--
There is something fascinating about science. One gets such wholesale
returns of conjecture out of such a trifling investment of fact.
-- Mark Twain

[tim.vanwa...@gmail.com]

Its is the entire frame if the argument that gave it away and the snotty way you refer to beaurocrats in the government. What I'm talking about has nothing to do with centralization. It has do do with how the government pays for what portion they pay and those experiments forming the models that the private sector companies will follow - voluntarily. They increasing have more incentive to change, only because they have saturated what the employers are willing to pay for their employees coverage and the increased costs are now being turned onto the secondary customers (you and me). But until lately, they've not been all that concerned with holding down costs because they could pass them onto the primary customers (employers) and the increased spliff they get was great for them. And as long as the government is dramatically warping the market through its involvement and they favorable tax status of the current scheme, your solution is theoretical hogwash. There is absolutely no role for the consumer to drive the prices when the consumer does not really pay those prices at the time of consumption. The only thing that would start to help in that matter would be for much higher deductibles, but as we see with Obamacare, those are both unpopular, and the biggest complaint that the Republicans have against the scheme.

And my skin in the game is simply helping rural healthcare survive. But because of that, I have lots of employees trying to help private practices adapt to whatever changes they have to make to survive. I would much rather they could spend that time helping improve patient care instead, so I don't benefit from the system like you think. However, because of what I do, I actually know what is occurring rather than knee jerking about based upon the perception that government=bad, free-market=good or vice versa. Since it is brutally obvious that Americans absolutely do not want a free market health care system, we have to work with the reality of what exists. And in that real world, regardless of what you think, the government IS the innovator at the moment because they have the most at stake and the biggest incentive to hold down costs.

believe me, I would not want to see single payer in the U.S. but pragmatically I know it is inevitable. If we make it until 2025 without it, I'll be surprised. The only thing propping up the current non-government side of the system up is tax policy. If they treated the employee compensation for healthcare like they did any other employee compensation, the entire system would collapse.

[agavi...@gmail.com]

"Too bad we're not getting the subsequent health improvement. for example, a drug or device manufacturing company now just has to show that their product is effective to be included in the standard of care and thus able to be reimbursed for. But it doesn't take enough account anything like DALY or QALY/$, so that new heartburn drug that costs 5x as much but is only 2% more effective and doesn't change the patient's quality of life is covered. Since the patient might bear the same cost no matter the bottom line to Medicare,..."

Medicare - the government- is the problem here. Insurance companies compete on the open market and their priority is maintaining a better or acceptable cost/benefit ratio compared to the competition in the market. Medicare has no such compunction.

As to health improvement, once again, the government has failed us. We're living longer these days, yet our largest therapeutic areas of concern are cardiology and obesity. These issues can directly be linked to the ridiculously incorrect government dietary standards to eat more carbs and fewer fats.

If the government could extricate itself from quite a lot "healthcare" we'd all be the better for it.

[J. Hugh Sullivan]

On Sun, 9 Jul 2017 21:43:18 -0700 (PDT), tim.vanwa...@gmail.com
wrote:

>Its is the entire frame if the argument that gave it away and the snotty wa=

>y you refer to beaurocrats in the government.

...as opposed to your position which, to me, appears to be "we don't
have enough talent to do it without government help". That's the
position of all socialists and people who can't compete.

Rural people didn't die in the 30s, 40s and 50s because of the lack of
insurance and advocates of socialistic policies.

Actually, in the late 40s I enjoyed the excess produce given to us by
a country doctor and his doctor son. Those vegetables were payment by
rural people who didn't have the cash. And they sat in the same
waiting room with those who could pay. It worked when people were
really competent.

[Con Reeder, unhyphenated American]

I'll pick out one sentence from your paragraph of preconceived notions:

> There is absolutely no role for the consumer to drive the prices
> when the consumer does not really pay those prices at the time of
> consumption.

That's rather the point, isn't it? When costs are not transparent,
how can they determine what they are paying?

> The only thing that would start to help in that matter
> would be for much higher deductibles, but as we see with Obamacare,
> those are both unpopular, and the biggest complaint that the
> Republicans have against the scheme.

Deductibles are already high. I am "lucky" to have insurance that
isn't the boa-constricter network Obamacare, and my deductible is
$3200, my out-of-pocket maximum $6500, and my premium 13,000 a year.
Obamacare would have similar provisions and a premium only slightly
less, at the cost of a network that is paper thin.

I'd much rather have a $8,000 deductible and a $6,000 premium, along
with the ability to choose care that minimized my outlay. And I'm old
and sick. If I were young, I'd love to have the chance to minimize
my costs by patronizing clinics, choosing which drug to treat with,
and using an HSA.

>
> And my skin in the game is simply helping rural healthcare survive.

Altruism personified.

> But because of that, I have lots of employees trying to help private
> practices adapt to whatever changes they have to make to survive. I
> would much rather they could spend that time helping improve patient
> care instead, so I don't benefit from the system like you think.
> However, because of what I do, I actually know what is occurring
> rather than knee jerking about based upon the perception that
> government=bad, free-market=good or vice versa. Since it is brutally
> obvious that Americans absolutely do not want a free market health
> care system, we have to work with the reality of what exists.

"My side's agenda is inevitable, so get on with it." Americans don't
want a free market health care system because the scaremongers of the
Democratic party accuse the opposition of improper motives. We have the
best health care in the world, and I want it to stay that way, not descend
to where Canada and Britain are. Where will the Canadian premier come
for his heart procedures if we go single-payer?

> And in that real world, regardless of what you think, the government
> IS the innovator at the moment because they have the most at stake
> and the biggest incentive to hold down costs.

Bullshit. The only incentive they have is to get elected and keep
their jobs.

> believe me, I would not want to see single payer in the U.S. but
> pragmatically I know it is inevitable. If we make it until 2025
> without it, I'll be surprised. The only thing propping up the current
> non-government side of the system up is tax policy. If they treated
> the employee compensation for healthcare like they did any other
> employee compensation, the entire system would collapse.

I think you are myopic. You can have the field, I'm done.

[wolfie]

"the_andr...@yahoo.com" wrote

> Medicare - the government- is the problem here. Insurance
> companies compete on the open market and their priority is
> maintaining a better or acceptable cost/benefit ratio compared
> to the competition in the market. Medicare has no such compunction.

And yet Medicare spending per enrollee has increased less than
the private market over the past 30 years. And continues to do
so. And is projected to continue. This is in spite of Medicare's
risk pool being much worse then the private industry, of course.

[Michael Press]

In article <1889e6f8-9c43-42a2...@googlegroups.com>,

Eat more fats. Fats are more satisfying per unit.
Allows stomach to shrink, hence less food fills stomach.

--
Michael Press

[TimV]

On Monday, July 10, 2017 at 7:09:36 AM UTC-5, J. Hugh Sullivan wrote:
> On Sun, 9 Jul 2017 21:43:18 -0700 (PDT), tim.vanwa...@gmail.com
> wrote:
>
> >Its is the entire frame if the argument that gave it away and the snotty wa=
> >y you refer to beaurocrats in the government.
>
> ...as opposed to your position which, to me, appears to be "we don't
> have enough talent to do it without government help". That's the
> position of all socialists and people who can't compete.

One, I'm not a socialist. Two, I'm not arguing that at all. There is infinitely more talent in the private sector to do this. They would be better at it. However, they are not doing it. All I am pointing out is that all the innovation that is occurring in this is happening within the government because they have the most currently at stake.

> Rural people didn't die in the 30s, 40s and 50s because of the lack of
> insurance and advocates of socialistic policies.

Yeah they did.

> Actually, in the late 40s I enjoyed the excess produce given to us by
> a country doctor and his doctor son. Those vegetables were payment by
> rural people who didn't have the cash. And they sat in the same
> waiting room with those who could pay. It worked when people were
> really competent.
>

That is fine when the majority of the costs is just the visit. But these days, the testing costs, prescriptions, and the like are far more than the human resources costs. For example, just to do a POC Hemoglobin A1C test, you're looking at $10 in phlebotomy supplies and a $15 cartridge for your DCA advantage. I had a steroid shot the other day for sinusitis and the cost was more than $100. Doctors cannot barter those costs away for some veggies Hugh.

The world has changed, medicine is far more precision oriented and far more expensive. Sure, if all a doctor was doing was looking down your throat and telling you to lose weight and quit smoking, it would be cheap. Now the capitalization costs alone for a new GP private practice is in the several hundreds of thousands for the equipment. So things were better in the 40's and 50's but general medicine was still pretty rudimentary at the time.

[TimV]

On Monday, July 10, 2017 at 7:28:28 AM UTC-5, Con Reeder, unhyphenated American wrote:
> I'll pick out one sentence from your paragraph of preconceived notions:
>
> > There is absolutely no role for the consumer to drive the prices
> > when the consumer does not really pay those prices at the time of
> > consumption.
>
> That's rather the point, isn't it? When costs are not transparent,
> how can they determine what they are paying?
>
> > The only thing that would start to help in that matter
> > would be for much higher deductibles, but as we see with Obamacare,
> > those are both unpopular, and the biggest complaint that the
> > Republicans have against the scheme.
>
> Deductibles are already high. I am "lucky" to have insurance that
> isn't the boa-constricter network Obamacare, and my deductible is
> $3200, my out-of-pocket maximum $6500, and my premium 13,000 a year.
> Obamacare would have similar provisions and a premium only slightly
> less, at the cost of a network that is paper thin.
>
> I'd much rather have a $8,000 deductible and a $6,000 premium, along
> with the ability to choose care that minimized my outlay. And I'm old
> and sick. If I were young, I'd love to have the chance to minimize
> my costs by patronizing clinics, choosing which drug to treat with,
> and using an HSA.
>
> >
> > And my skin in the game is simply helping rural healthcare survive.
>
> Altruism personified.

No, my job is to support innovative ways to improve the health outcomes in our state. Again, I would prefer that my staff could just focus on that rather than helping private business try to limp over the finish line.

> > But because of that, I have lots of employees trying to help private
> > practices adapt to whatever changes they have to make to survive. I
> > would much rather they could spend that time helping improve patient
> > care instead, so I don't benefit from the system like you think.
> > However, because of what I do, I actually know what is occurring
> > rather than knee jerking about based upon the perception that
> > government=bad, free-market=good or vice versa. Since it is brutally
> > obvious that Americans absolutely do not want a free market health
> > care system, we have to work with the reality of what exists.
>
> "My side's agenda is inevitable, so get on with it." Americans don't
> want a free market health care system because the scaremongers of the
> Democratic party accuse the opposition of improper motives. We have the
> best health care in the world, and I want it to stay that way, not descend
> to where Canada and Britain are. Where will the Canadian premier come
> for his heart procedures if we go single-payer?

Yeah, always those evil Demoncrat's fault. By any objective measure, we do not have the best healthcare system in the world. We have the most expensive system. And yeah, Canada's system sucks. There are plenty that do not.

>
> > And in that real world, regardless of what you think, the government
> > IS the innovator at the moment because they have the most at stake
> > and the biggest incentive to hold down costs.
>
> Bullshit. The only incentive they have is to get elected and keep
> their jobs.

Not really, but ok. Government is always evil. It's nice when life can be distilled into simple black and white. I'm just telling you the facts. I'm not arguing that the government should be the innovator. But feel free to show me all the innovative things that the private sector is doing to try to hold down costs and alter the broken fee-for-service models. And then when you do, show me where the original research came from that they are building that off of. That would be far more productive to this conversation than platitudes about how bad government is and how angelic the free market would be.

>
> > believe me, I would not want to see single payer in the U.S. but
> > pragmatically I know it is inevitable. If we make it until 2025
> > without it, I'll be surprised. The only thing propping up the current
> > non-government side of the system up is tax policy. If they treated
> > the employee compensation for healthcare like they did any other
> > employee compensation, the entire system would collapse.
>
> I think you are myopic. You can have the field, I'm done.
>

Yeah, I'm the myopic one. But I have the field anyway since I actually am informed about what is happening rather than just applying a general worldview but this is not some appeal to authority here. I have not once argued that what is happening is right or the best practice. I would be happy to be proven wrong on what is actually happening to fix healthcare since, again, the argument I am making is not how something should be done but what is actually being done. I have simply just said what is actually happening, to which you are incredulous.

Argue all you want about how the system should be structured, how health care should be paid for, and what a proper free market system should look like. Argue that the entry of the government into the market as a payer, and not simply as a regulator, has distorted the system and completely broken it. Those are nice intellectual arguments and you will find that I would agree with virtually everything (with the exception of emergency care since the power and information differential is too great for a totally real free market solution). Just because I explain what is going on and have a realistic assessment of our health care system and where it seems to be headed doesn't mean I'm a liberal. But I did vote for a Democrat for a local office last time and that does negate the rest of the Republicans and Libertarians I voted for, so I must be some Commie who is completely nearsighted.

Tim

[michael anderson]

This is a lot of rural areas/rural medicine right? I'm not sure that there is any real fix for those problems as so much of the issue there, especially on an inpatient basis, is just due to the fact that they can't recruit qualified/competent providers there.
My group covers an inpatient geri psych unit 2 days a week in person about 90 miles out and the stipend they have to pay us on top of the regular billing codes we submit is just insane. It's the same for every group of most specialties they have come provide inpatient coverage/consults. It's gotta be bankrupting their system.....I don't know that there is a 'solution' for this problem....short of closing the hospital down and funneling all those patients to an area where providers already are(which is probably the best idea)

[TimV]

-----------------------------------------------

To some extent, sure. But whether we are talking about primary care or hospitals, the answer is not just closing down and funneling their care to populated places. That works on the East Coast where rural means the subway doesn't get there and 90 miles might get you across your state and halfway into the next. In places like Utah, Montana, Nevada or Alaska, where we already have extreme rural health disparities, the answer can't be just to let them go several hours to get that foot sore looked at. One, that will in the end drive up the cost of care even more, accelerate the onset of medically induced disabilities, and virtually destroy rural America. Very few would be willing to live or companies willing to stay or relocate in areas where even simple primary medical care requires an entire day to access. And contrary to what many Americans seem to understand, those rural areas are pretty vital to the American economy. No basic health care in rural America, means no rural economy, which means America's most potent source and advantage for its wealth - its incredible agricultural machine, wouldn't necessarily fully shut down, but would have to lead to decreased output and higher costs.

Normally I would say leave this up to the states, but our rural agricultural capabilities are a strategic national resource that is more like national defense. We cannot leave that solely to the profit pressures of short-term thinking investors (some of which are not concerned at all with America's strategic survival). We already have seen urban healthcare systems buying up rural practices but then spitting back out the ones in the most rural areas because they are not profitable. The government should not be in the business of propping up unprofitable enterprises unless those enterprises are in the strategic national interest of the US. In rural American, the John Deere dealer isn't. You can always drive 90 miles to get a new rig or new parts. But healthcare, for the reasons I note above, are.

I don't know the answer, don't claim to know the answer, and simply have begged our policymakers to start to address it. For now, I am just trying to provide the resources to those practices to help them be more efficient, especially in the ability to actually effectively recapture their costs. Maybe that will be enough with some state-based incentives thrown in. Again, I would rather they be able to be involved in research that would more cost and outcomes-wise effectively reduce cardiovascular risk, diabetes and obesity, etc. Instead, we have to provide help for them just to keep the doors open just so that the research can be done as a byproduct.

[Con Reeder, unhyphenated American]

On 2017-07-10, TimV <tim.van...@gmail.com> wrote:
>> > And in that real world, regardless of what you think, the government
>> > IS the innovator at the moment because they have the most at stake
>> > and the biggest incentive to hold down costs.
>>
>> Bullshit. The only incentive they have is to get elected and keep
>> their jobs.
>
> Not really, but ok. Government is always evil. It's nice when life
> can be distilled into simple black and white. I'm just telling you
> the facts. I'm not arguing that the government should be the
> innovator. But feel free to show me all the innovative things that
> the private sector is doing to try to hold down costs and alter the
> broken fee-for-service models.

I think you can just observe the dental, vision, and plastic surgery
markets to see that. The same thing would happen if we gave real
incentive to patients to shop for other types of health care.

> And then when you do, show me where
> the original research came from that they are building that off of.

Research? What are you even talking about? Efficiency doesn't require
research, and it doesn't spring from it. It ain't rocket science, it's
hustle, incentives, and investment.

> That would be far more productive to this conversation than
> platitudes about how bad government is and how angelic the free
> market would be.

I think government is great when it is employed for proper purposes
like enforcing property rights, building a limited set of the commons,
providing for our defense, and enforcing basic human rights.

As a model for providing goods and services, it sucks. There is just
no incentive for a government employee to do anything except cover their
ass and keep their job. If you can show me a real incentive then I'd listen.
But you can't. (No, altruism doesn't count. Nor does attaboys and a gold watch.)

--
People who want to share their religious views with you
almost never want you to share yours with them. -- Dave Barry

[wolfie]

"Con Reeder, unhyphenated American" wrote

> There is just no incentive for a government employee
> to do anything except cover their ass and keep their job.

The same is true for the vast majority in the private
sector.

[xyzzy]

In general Connie's right here. But so are you. Actually sometimes more so in the private sector where you can more easily lose your job.

[Con Reeder, unhyphenated American]

True in some cases. But private industry is quite good about giving
promotions and/or extra pay based on real ability, so you have an
incentive to go above and beyond. Also, from long experience, managers
are not at all promoted for being CYA in good companies. They are
fired for it if that activity gets in the way of their job and the
results they are supposed to get.

[TimV]

On Monday, July 10, 2017 at 1:35:01 PM UTC-5, Con Reeder, unhyphenated American wrote:
> On 2017-07-10, TimV <tim.van...@gmail.com> wrote:
> >> > And in that real world, regardless of what you think, the government
> >> > IS the innovator at the moment because they have the most at stake
> >> > and the biggest incentive to hold down costs.
> >>
> >> Bullshit. The only incentive they have is to get elected and keep
> >> their jobs.
> >
> > Not really, but ok. Government is always evil. It's nice when life
> > can be distilled into simple black and white. I'm just telling you
> > the facts. I'm not arguing that the government should be the
> > innovator. But feel free to show me all the innovative things that
> > the private sector is doing to try to hold down costs and alter the
> > broken fee-for-service models.
>
> I think you can just observe the dental, vision, and plastic surgery
> markets to see that. The same thing would happen if we gave real
> incentive to patients to shop for other types of health care.
>
> > And then when you do, show me where
> > the original research came from that they are building that off of.
>
> Research? What are you even talking about? Efficiency doesn't require
> research, and it doesn't spring from it. It ain't rocket science, it's
> hustle, incentives, and investment.

Seriously? You don't think any research goes into efficiency? I suppose if your job is just to shovel manure into a pasture, efficiency is just a matter of working harder, investing in a really good shovel, and getting paid by the ton. But I don't think the answer to our healthcare problems is just to have clinicians work harder. So then to determine the best ways to make investments and incentivize efficiency is this little thing called research. The answers don't magically appear when you shake a little 8 ball.

Lots and lots of research goes into how to be more effective on cost and outcomes both on the delivery and payment side of health care. And of course similar efficiency issues occur in any complicated businesses. Even the process of figuring out what the best incentives are to motivate employee production is research. Heck lots of research goes into where to make investments. Human behavioral research is critical to driving efficient use of advertising revenue, sales, product placement, HR, physical plant locations, ad nauseum.

[xyzzy]

On Monday, July 10, 2017 at 2:35:01 PM UTC-4, Con Reeder, unhyphenated American wrote:
> On 2017-07-10, TimV <tim.van...@gmail.com> wrote:
> >> > And in that real world, regardless of what you think, the government
> >> > IS the innovator at the moment because they have the most at stake
> >> > and the biggest incentive to hold down costs.
> >>
> >> Bullshit. The only incentive they have is to get elected and keep
> >> their jobs.
> >
> > Not really, but ok. Government is always evil. It's nice when life
> > can be distilled into simple black and white. I'm just telling you
> > the facts. I'm not arguing that the government should be the
> > innovator. But feel free to show me all the innovative things that
> > the private sector is doing to try to hold down costs and alter the
> > broken fee-for-service models.
>
> I think you can just observe the dental, vision, and plastic surgery
> markets to see that. The same thing would happen if we gave real
> incentive to patients to shop for other types of health care.

Add veterinary to that

[Con Reeder, unhyphenated American]

You apparently don't even understand the problem if you think
this means "clinicians work harder".

> So then to determine the best ways to make investments and
> incentivize efficiency is this little thing called research. The
> answers don't magically appear when you shake a little 8 ball.

You seem to know know close to zero about economics and running a
business. It is time for me to stop.

--
The sun, with all those planets revolving around it and
dependent on it, can still ripen a bunch of grapes as if
it had nothing else in the universe to do. -- Galileo

[tim.vanwa...@gmail.com]

In other words Connie, you got owned. You're arguing about something you know absolutely nothing about against someone who does this for a living. And because reality doesn't fit your narrow worldview, it's me that knows nothing about economics.

Please go back to schooling me on how efficiency doesn't require any research. That's a classic. Then again, your argument was so ridiculous that perhaps I'm being trolled and should take the hook out now.

[J. Hugh Sullivan]

On Mon, 10 Jul 2017 09:27:26 -0700 (PDT), TimV
<tim.van...@gmail.com> wrote:

>The world has changed, medicine is far more precision oriented and far more=
> expensive. Sure, if all a doctor was doing was looking down your throat an=
>d telling you to lose weight and quit smoking, it would be cheap. Now the c=
>apitalization costs alone for a new GP private practice is in the several h=
>undreds of thousands for the equipment. So things were better in the 40's a=

>nd 50's but general medicine was still pretty rudimentary at the time.
>

>---
>This email has been checked for viruses by AVG.
>http://www.avg.com

You certainly post some intelligent views on the issue. The medical
service provided me, if provided my dad, would have allowed him to
live more than 63 years - and my mom might have survived her hip
surgery.

When I retired the company I worked for had retiree insurance almost
identical to Medicare. Medicare in effect usurped it, i. e. why pay
for it if the government will. Why? Because it costs a helluva lot
more when government is involved. Why? Everyone is viewed as the same
person - retirees of the company I worked for were pretty special
compared to the same mold people covered by government insurance. If
some could not qualify to work at the company I did it's not the duty
of the government to interfere.

Aside from being more costly my basis is that the government should
not be involved in more thatn guaranteeing equal opportunity other
than establishing some basic standards for care. Government should not
handicap a people race like a horse race.

Out of curiosity where were you during the 30s and 40s to observe
people dying solely because they did not have health care insurance? I
did not know many people who even had health insurance.

Hugh

[agavi...@gmail.com]

Medicare is spending less on patients than private insurance?

No shit?

Ain't that something?

We should all aspire to be covered by Medicare.

[tim.vanwa...@gmail.com]

You all have been 'to a dentist and vet lately right? Those aren't exactly two great examples of business holding down prices for the consumer. Thus the proliferation of dental and pet insurance. And last I looked, the average cost of Lasix was a third of the US price in Canada.

Even the supposedly more free market medical service, including vet services, suffer from the high medical inflation and costs. We are seeing that spread even through the allied health fields. Everybody wants to get paid.

[J. Hugh Sullivan]

It means you would not have to look at grass from the root side for a
while yet.

Hugh

[Con Reeder, unhyphenated American]

On 2017-07-10, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:

Think what you like. To me, it looks like if you do actually know anything
you are so far lost in the trees you can't find the forest.

When you can compare and contrast the current health care market and
its economic state compared to 40 years ago, with the vision market now
and 40 years ago, then I'll listen to you. Price transparency, were it to
be tried, would cause an explosion of innovation. It would also cause a
great reduction in the profits of doctors, hospitals, and insurance companies,
which is why they fight tooth and nail against it.

--
When the only tool you have is a hammer, all your problems tend to look
like nails. -- Abraham Maslow

[tim.vanwa...@gmail.com]

Maybe Connie. But not as long as consumers are not directly paying the costs. You completely ignore the current system (and you get no disagreement on me that the government entry exacerbated the problem. I have said so repeatedly). At the very minimum, the payers have to incentivize the consumers to price shop. For me, it doesn't matter if my heart valve replacement costs 25k or 35k. I pay EXACTLY the same either way. So what would matter to me might be convenience, timing, or how I perceive the competence of the doctor. In fact, price transparency could actually backfire with how healthcare is currently paid - human behavioral research clearly shows that consumers assume that higher prices mean greater value. Thus, in any situation where their out of pocket costs are the same, they might still choose the more expensive option.

Some insurers have started to waive certain patient costs if they will use some centers, like the OKC surgery center with upfront pricing. However, that can be of very limited appeal because it requires the patient to front all of the costs and get reimbursed by the insurance company. Given the poor savings of the average American, most can't afford to do that even if it would save them money in the end on their portion of the bill.

But apparently I'm the idiot who doesn't understand economics and thinks that research is a valuable component to identifying efficiencies so what do I know.

[michael anderson]

On Monday, July 10, 2017 at 8:51:59 PM UTC-5, Con Reeder, unhyphenated American wrote:
> On 2017-07-10, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
> > In other words Connie, you got owned. You're arguing about something
> > you know absolutely nothing about against someone who does this for a
> > living. And because reality doesn't fit your narrow worldview, it's me
> > that knows nothing about economics.
> >
> > Please go back to schooling me on how efficiency doesn't require any
> > research. That's a classic. Then again, your argument was so
> > ridiculous that perhaps I'm being trolled and should take the hook
> > out now.
>
> Think what you like. To me, it looks like if you do actually know anything
> you are so far lost in the trees you can't find the forest.
>
> When you can compare and contrast the current health care market and
> its economic state compared to 40 years ago, with the vision market now
> and 40 years ago, then I'll listen to you. Price transparency, were it to
> be tried, would cause an explosion of innovation. It would also cause a
> great reduction in the profits of doctors, hospitals, and insurance companies

what is it with this viewpoint you have that doctors, hospitals, and insurers are on the same side? I can most definately state that that is not usually the case.

Not so much from my own experiences but thats part of it(because psychiatry does things differently in some ways that other specialties especially procedure based specialties), but combining that with those in my family in medicine who tell me their experiences. We are definately not on the side of hospitals and insurers here...they are on the other side.

[Con Reeder, unhyphenated American]

On 2017-07-11, michael anderson <miande...@gmail.com> wrote:
> On Monday, July 10, 2017 at 8:51:59 PM UTC-5, Con Reeder, unhyphenated American wrote:
>> On 2017-07-10, tim.vanwa...@gmail.com <tim.vanwa...@gmail.com> wrote:
>> > In other words Connie, you got owned. You're arguing about something
>> > you know absolutely nothing about against someone who does this for a
>> > living. And because reality doesn't fit your narrow worldview, it's me
>> > that knows nothing about economics.
>> >
>> > Please go back to schooling me on how efficiency doesn't require any
>> > research. That's a classic. Then again, your argument was so
>> > ridiculous that perhaps I'm being trolled and should take the hook
>> > out now.
>>
>> Think what you like. To me, it looks like if you do actually know anything
>> you are so far lost in the trees you can't find the forest.
>>
>> When you can compare and contrast the current health care market and
>> its economic state compared to 40 years ago, with the vision market now
>> and 40 years ago, then I'll listen to you. Price transparency, were it to
>> be tried, would cause an explosion of innovation. It would also cause a
>> great reduction in the profits of doctors, hospitals, and insurance companies
>
> what is it with this viewpoint you have that doctors, hospitals, and
> insurers are on the same side? I can most definately state that that
> is not usually the case.

They have differing incentives, but none of them include incentives to
be transparent in price. Neither doctors nor hospitals want you to know
how much things cost, as you might shop and they might have to lower their
price. Insurance companies incentives are a bit different, because they
have networks and reimbursement schemes. They want to retain the current
system, because they make their money by having all health care dollars
pass through their mitts where they rake their share. If they are simply
catastrophic insurers for the most part, they lose that.

> Not so much from my own experiences but thats part of it(because
> psychiatry does things differently in some ways that other specialties
> especially procedure based specialties), but combining that with those
> in my family in medicine who tell me their experiences. We are
> definately not on the side of hospitals and insurers here...they are
> on the other side.

None of you are on the side of the patient. Hospitals fight to keep
certificates of need, doctors fight to keep license requirements for
different procedures, etc.

--
Being against torture ought to be sort of a bipartisan thing.
-- Karl Lehenbauer

[michael anderson]

On Monday, July 10, 2017 at 10:36:58 PM UTC-5, Con Reeder, unhyphenated American wrote:

> They have differing incentives, but none of them include incentives to
> be transparent in price.

If you asked me I could tell you in 2 seconds what each of my codes pay. A lot of providers for at least their most common codes could do the same thing.

So from the provider end, I don't neccessarily buy this.

Perhaps from the hospital end it's different.

[tim.vanwa...@gmail.com]

I'll just leave this here, and a note that in at least half of the states hospitals have to disclose their prices if you call. Very few patients call.

http://jamanetwork.com/journals/jama/fullarticle/2518264

[J. Hugh Sullivan]

On Mon, 10 Jul 2017 20:28:24 -0700 (PDT), michael anderson
<miande...@gmail.com> wrote:

>what is it with this viewpoint you have that doctors, hospitals, and insure=
>rs are on the same side? I can most definately state that that is not usua=
>lly the case.

I agree - with examples...

My GP can't even admit patients to the hospital or see them there -
his choice. But that's fine - the hospital is always my last choice.
My kidney doctor has his own facility but he has admittance
privileges. My heart doctor left the hospital and opened his own
place. The hospital handled that poorly and I told them so
face-to-face.

All three believe Medicare cheats them out of income and causes them
to hire more employees to do government paper work than those who help
treat people with problems.

[J. Hugh Sullivan]

On Mon, 10 Jul 2017 22:09:21 -0700 (PDT), tim.vanwa...@gmail.com
wrote:

>I'll just leave this here, and a note that in at least half of the states hospitals have to disclose their prices if you call. Very few patients call.

Why should they call if Obamaasses tax responsible people to pay the
price for the irresponsible and worthless people?

I live in a world where quality matters a helluva lot more than price.
I choose my doctors by reputation instead of looking to see if some
docinabox is having a sale. I spent 33 years in the Naval Reserve and
worked for 37 years years to entitle me to do that. I have no sympathy
for people who did nothing to earn service for their needs - or for
liberals who kiss their ass.

Traitorous liberals don't agree because they don't plan that well and
they don't think others who don't should suffer because of the
stupidity of both.

[JGibson]

On Tuesday, July 11, 2017 at 1:09:24 AM UTC-4, tim.vanwa...@gmail.com wrote:
> I'll just leave this here, and a note that in at least half of the states hospitals have to disclose their prices if you call. Very few patients call.
>
> http://jamanetwork.com/journals/jama/fullarticle/2518264

So, this summer we decided we need to extend the driveway to our house. We have called six people and have managed to obtain 3 quotes. We're not entirely happy, so we haven't gone with any of them yet. It will be an inconvenience without the extension but we can live without it, so not buying is an option. When I was writhing in pain due to a kidney stone, I wasn't about to call around and see who was going to be the cheapest to take care of it.

[wolfie]

"J. Hugh Sullivan" wrote

> Why should they call if Obamaasses tax responsible
> people to pay the price for the irresponsible and worthless
> people?

Responsible people have ALWAYS paid for the poor.

Even in your halcyon days doctors had to charge people
with cash more - you can only eat so much chicken and
veggies. And neither of those pay the mortgage or put
gas in the car. So they made up for it by charging people
paying money more than they would otherwise.

I'd rather pay a bit more in taxes and know that when
that irresponsible person has a heart attack the hospital
gets paid, so my prices don't have to be jacked-up.

Since you're on socialized medicine you don't care.
Well, until they close down a hospital close to you
because they're treating too many irresponsible
people w/o getting paid and you die on an ambulance
ride to one further away, anyway.

What I don't get is why you don't approve of the *fact*
that the subsidy isn't a total-dollar benefit. The poor and
irresponsible HAVE to pay some and make a start at being
responsible, or the government takes some of their money.
Isn't that a good thing?

[agavi...@gmail.com]

You should know that beforehand.

I (okay my wife) already knows where we should go in certain situations.

[TimV]

On Tuesday, July 11, 2017 at 9:55:06 AM UTC-5, the_andr...@yahoo.com wrote:
> You should know that beforehand.
>
> I (okay my wife) already knows where we should go in certain situations.

So your wife has determined the best prices of where to get various medical emergency procedures, or your wife has determined the best places to get various medical procedures based on reputation like competency, convenience, and outcomes. Say, like the local specialty heart hospital, level 3 trauma center, or cancer center, rather than that community or academic medical center.

Because if the latter, thank you for making my point.

[Con Reeder, unhyphenated American]

Of course not. But you can make general provider choices based on
all sorts of factors. I am not saying price is the be-all and end-all.
I don't go to the cheapest heart clinic; their standing in the industry
combined with a reasonable price is what what I am looking for.

These types of things are on the margin. But the general tendency is
for competition to make the market more efficient.

--
"All you need in this life is ignorance and confidence, and
then success is sure." -- Mark Twain

[agavi...@gmail.com]

I was making your point, dumnblebass.

Yes, we know where we're balancing costs/competence.

Some doctors we won't change regardless of our out of pocket expenses. Others are purely exonomic.

...and cancer is a terrible example relative to the critical care example of a kidney stone (which, by the way, I had a couple years back and drive past several adequate facilities to one that met my economic criteria.

[michael anderson]

On Tuesday, July 11, 2017 at 9:11:54 AM UTC-5, wolfie wrote:
> "J. Hugh Sullivan" wrote
>
> > Why should they call if Obamaasses tax responsible
> > people to pay the price for the irresponsible and worthless
> > people?
>
> Responsible people have ALWAYS paid for the poor.
>
> Even in your halcyon days doctors had to charge people
> with cash more - you can only eat so much chicken and
> veggies. And neither of those pay the mortgage or put
> gas in the car. So they made up for it by charging people
> paying money more than they would otherwise.
>

No, you don't get it. Doctors 'have' to charge uninsured people more in some cases than insured people because they CANNOT charge less than the HIGHEST insurance payment for that code. For example, if my reimburses for a certain code are as follows:

medicare- 198
Aetna- 187
Blue Cross- 211
Humana- 234

And I take those 4 insurances, then I CANNOT charge less than 234 for self pay patients. Why? Because if I did, Humana would refuse to pay the 234 that they pay now. A lot of people outside health care don't understand that's how we set our self pay rates. It has nothing to do with trying to gouge the uninsured, or trying to make up for uninsured who don't pay....It is simply about making sure we get out contractual rates from the insurance contracts we have.

Now in a lot of cases there is one high outlier for any given code in terms of what an insurer will pay, and that's how people get the impression the self pay rates are so much higher.

[xyzzy]

This is the most useful piece of information you've poasted in a long time.

[wolfie]

"michael anderson" wrote

> Doctors 'have' to charge uninsured people more in
> some cases than insured people because they
> CANNOT charge less than the HIGHEST insurance
> payment for that code. For example, if my
> reimburses for a certain code are as follows:

> medicare- 198
> Aetna- 187
> Blue Cross- 211
> Humana- 234

> And I take those 4 insurances, then I CANNOT
> charge less than 234 for self pay patients. Why?
> Because if I did, Humana would refuse to pay the 234
> that they pay now.

You realize you just pointed out exactly what's wrong
with the health care industry? You're willing to provide
the service for $187. WTF are you charging others more?

Fix your example, fix the issue. Simple law: "No medical
provider can charge more than they charge Medicare for
any procedure, exam, etc." Of course, single payer would
do exactly that, but it's your example that needs fixing, not
the assortment of payers.

[tim.vanwa...@gmail.com]

There is absolutely nothing wrong with charging different things to different people. Outside of pure retail, that's pretty much how all of business works and is absolutely essential to the entire free enterprise system.

Pegging all payments to medicare rates is an atrocious idea. The medical provider doesn't decide what they charge medicare for a particular procedure. That is set by the government. Government deciding what they are willing to pay for something is perfectly reasonable as long as they do not compel the individual to provide that service. In some cases, that payment is actually below the costs for the provider, or barely covers the actual costs without any consideration to capitalization costs, etc. Any government fixing prices for anything else has been proven over and over again to be a road to disaster.

[agavi...@gmail.com]

WTF are you charging others more?

Volume Discounts
Referral Fees

These are all pretty standard concepts

[wolfie]

tim.vanwa...@gmail.com wrote

> Government deciding what they are willing to pay for
> something is perfectly reasonable as long as they do
> not compel the individual to provide that service.

And they don't. So no problem.

[michael anderson]

On Tuesday, July 11, 2017 at 1:49:13 PM UTC-5, wolfie wrote:

> "michael anderson" wrote
>
> > Doctors 'have' to charge uninsured people more in
> > some cases than insured people because they
> > CANNOT charge less than the HIGHEST insurance
> > payment for that code. For example, if my
> > reimburses for a certain code are as follows:
>
> > medicare- 198
> > Aetna- 187
> > Blue Cross- 211
> > Humana- 234
>
> > And I take those 4 insurances, then I CANNOT
> > charge less than 234 for self pay patients. Why?
> > Because if I did, Humana would refuse to pay the 234
> > that they pay now.
>
> You realize you just pointed out exactly what's wrong
> with the health care industry? You're willing to provide
> the service for $187. WTF are you charging others more?
>

huh? Are you serious?

I'm agreeing to take less from some payers *BECAUSE I WANT TO*. It could be based on any number of factors- such as complexity of the typical patients from that payer source, amount of administrative paperwork/hassle from that payer source, etc....there are cases where I am on one insurance panel that pays less than an inpatient insurance panel I refuse to be a part of because the insurance panel that pays more for my most common inpatient codes is unreasonable when it comes to peer reviews and documenting medical neccessity.

The fact that you even pose the question that way shows how little you know about the issue imo.

[michael anderson]

On Tuesday, July 11, 2017 at 1:49:13 PM UTC-5, wolfie wrote:

Of course, single payer would
> do exactly that, but it's your example that needs fixing, not
> the assortment of payers.

If we instituted a medicare for all system tommorrow(and only medicare for everyone) and the codes stayed exactly the same, I'd make another 150-180k per year easy. Due to a number of factors(I'd have far fewer days/codes not covered would be the biggest).

Actually a lot of non-procedure high volume based specialties would either do a little better or about the same.

The procedure based specialties, especially those that arent high volume, would take a big hit.

But thats not the main issue with single payer. The main issue is that if you only had ONE payer, then what is to stop them from slashing rates to absurd levels? Right now they can't do that for obvious reasons. So while I might be satisfied with what medicare now pays for a full level inpatient psych H&P, if they were the *only player* in the game that would scare the shit out of me and every other provider because rates may plummet...

[tim.vanwa...@gmail.com]

Your proposed law stated the can't charge more that what they charge Medicare. A provider doesn't decide what they charge Medicare. While some providers can choose not to accept Medicare patients or choose what percentage of their patient mix are covered by Medicare, as a whole, most providers must accept at least some of them just to financially survive. Thus, a law like that would be a de facto governmental price control.

[wolfie]

"michael anderson" wrote

> if they were the *only player* in the game that
> would scare the shit out of me and every other
> provider because rates may plummet...

Single-payer's coming. Already being discussed
in two states, with more to come. With Dolt 45
a disaster for the GOP, it won't be long.

[wolfie]

tim.vanwa...@gmail.com wrote

> Thus, a law like that would be a de facto
> governmental price control.

Yeah, that's part of why other countries on
different single payer options get a better
cost ratio out of their health care dollar.
That's not a bug; it's a feature.

BTW, is it a "de facto governmental price
control" if a single private company has a
virtual monopoly on health care insurance
plans in an area and uses it to drive down
its costs?

Asking for a friend. ($1)

[michael anderson]

I think we can stave it off(complete single payer) for most of my career. But if it does tragically come and reimbursements plummet, I just won't take it. I'm fortunate enough to work in an area of medicine where there is a thriving cash market now similar to dentistry. Of course it would mean changing the nature of my practice(would have to move from an inpatient to outpt and contract work focus), but I'd be fine....

A lot of other providers in other areas would be able to transition to a similar system. If single payer did come and reimbursements stayed the same or increased slightly, I'd be fine with that. I just don't think it's going to happen as soon as you and other libs think...

[J. Hugh Sullivan]

On Tue, 11 Jul 2017 14:49:07 -0400, "wolfie" <bgbd...@gte.net> wrote:


>Fix your example, fix the issue. Simple law: "No medical
>provider can charge more than they charge Medicare for
>any procedure, exam, etc." Of course, single payer would
>do exactly that, but it's your example that needs fixing, not
>the assortment of payers.

Doctors charge Medicare for a procedure. Medicare reduces the amount
to what they will allow. Then they pay 80% for MOST services.

The Medicare allowable reduces the billed amount - sometimes as much
as 40%. I used to keep track of every amount billed and the allowable.

So, in effect doctors do not charge patients more than they charge
Medicare.

I'm willing to pay extra for superior care. It's not my fault that
some can't and liberals are increasing the number of those.

[J. Hugh Sullivan]

On Tue, 11 Jul 2017 12:47:25 -0700 (PDT), tim.vanwa...@gmail.com
wrote:


>There is absolutely nothing wrong with charging different things to differe=
>nt people. Outside of pure retail, that's pretty much how all of business w=

>orks and is absolutely essential to the entire free enterprise system.

It's elementary.

>
>Pegging all payments to medicare rates is an atrocious idea.

Tht's the only kind wolfie has.

>The medical pr=
>ovider doesn't decide what they charge medicare for a particular procedure.=

> That is set by the government.

To be precise the provider DOES charge his fee which is not set by
government. What Medicare will pay is set by the government. In 24
years I have not seen it work differently.

[J. Hugh Sullivan]

On Tue, 11 Jul 2017 10:11:47 -0400, "wolfie" <bgbd...@gte.net> wrote:

>
>
>"J. Hugh Sullivan" wrote
>
>> Why should they call if Obamaasses tax responsible
>> people to pay the price for the irresponsible and worthless
>> people?
>
>Responsible people have ALWAYS paid for the poor.

Yep - but liberals in all their socialistic stupidity added government
to solve a problem that was already solved.

>
>Even in your halcyon days doctors had to charge people
>with cash more - you can only eat so much chicken and
>veggies. And neither of those pay the mortgage or put
>gas in the car. So they made up for it by charging people
>paying money more than they would otherwise.

Yeah, prices for a home visit by the doctor were a little more than
the $10 office visit.

>I'd rather pay a bit more in taxes and know that when
>that irresponsible person has a heart attack the hospital
>gets paid, so my prices don't have to be jacked-up.

I'm glad to see that you pay taxes. Heretofore I doubted your ability
to earn income other than the military.

The government being in charge adds considerable to the cost - they
have to hire a slew of employees to take care of the paperwork and
their wages have to be paid. I get a bill after Medicare but before
Tricare. Then I get a zero bill after Tricare pays. That's salary,
computer and paper plus postage. Like I didn't know the answer before
them.

I had a doctor visit last week. I always present a computer listing of
personal data, medicine/dosage/prescriber, doctors names and info,
surgeries, diagnoses and innoculations to the nurse. Then the APRN
asked about what surgeries I had. I have difficulty comprehending how
dumb some people are nowadays.

Seems like everyone take all the medical cards for doctor visits. I
scanned my cards and take the printout - so I don't have to put all
the cards in my very thin billfold. Can't anyone else train those
people?

>Since you're on socialized medicine you don't care.

I care that liberals were so stupid as to replace affordable corporate
retiree insurance with costly socialist policy. Because Medicare and
Social Security are stupid I'll drain them for all I can. Stupid
liberals were put here to be taken advantage of, not ignored.

>Well, until they close down a hospital close to you
>because they're treating too many irresponsible
>people w/o getting paid and you die on an ambulance
>ride to one further away, anyway.

What is the alternative to dying? And I griped because the new
hospital was built 12 minutes away vice 5 minutes.

>What I don't get is why you don't approve of the *fact*
>that the subsidy isn't a total-dollar benefit. The poor and
>irresponsible HAVE to pay some and make a start at being
>responsible, or the government takes some of their money.
>Isn't that a good thing?

The first response is that socialism is NEVER a good thing.

I know at least one person on Medicaid who pays nothing so there are
probably others. Your position has no basis. I know one family that
works, must pay for health care insurance and can't afford all the
necessities because there is not enough money left.

I know several people who accept only cash for services to avoid taxes
and receive subsidies. But they do good work and are less expensive.

Our starting points are different. You believe the government is
essential to taking care of incompetent people. I was alive when
government was not required for that.

The result of your position has been an exponential growth in the
number of incompetents and the min wage people required to serve them.
And you appear to think that is a good thing.

[wolfie]

"J. Hugh Sullivan" wrote
"wolfie" wrote

>>What I don't get is why you don't approve of the *fact*
>>that the subsidy isn't a total-dollar benefit. The poor and
>>irresponsible HAVE to pay some and make a start at being
>>responsible, or the government takes some of their money.
>>Isn't that a good thing?

> I know at least one person on Medicaid who pays
> nothing so there are probably others. Your position
> has no basis.

As SCOTUS pointed out, Medicare isn't Obamacare.
You're either ignorant, wrong, or dodging the question.

[J. Hugh Sullivan]

On Wed, 12 Jul 2017 16:30:50 -0400, "wolfie" <bgbd...@gte.net> wrote:

>"J. Hugh Sullivan" wrote
>"wolfie" wrote
>
>>>What I don't get is why you don't approve of the *fact*
>>>that the subsidy isn't a total-dollar benefit. The poor and
>>>irresponsible HAVE to pay some and make a start at being
>>>responsible, or the government takes some of their money.
>>>Isn't that a good thing?
>
>> I know at least one person on Medicaid who pays
>> nothing so there are probably others. Your position
>> has no basis.
>
>As SCOTUS pointed out, Medicare isn't Obamacare.

So that's why you know the difference.

>You're either ignorant, wrong, or dodging the question.

Or, pointing out your lie about poor and irresponsible having to pay.

Having to pay some makes them irritable, not responsible.

[wolfie]

"J. Hugh Sullivan" wrote

>>"wolfie" wrote
>
>>>What I don't get is why you don't approve of the *fact*
>>>that the subsidy isn't a total-dollar benefit. The poor and
>>>irresponsible HAVE to pay some and make a start at being
>>>responsible, or the government takes some of their money.
>>>Isn't that a good thing?

> Or, pointing out your lie about poor and irresponsible having to pay.

We're talking about the subsidy for Obamacare, not medicare.

[J. Hugh Sullivan]

The UnACA will implode without help from the GoP. The threat to void
the act will just hasten the end. The UnACA and Medicaid are just a
more costly way to take care of the handicapped (physical and talent)
and the worthless.

Government intervention in healthcare only means you have to be the
patient of an incompetent at times 'cause government regards him the
same as competents. Competent robots eliminating the need for humans
is a better option. Hail to Watson.

Some of us earn the right to be privileged - but at varying degrees. I
would have willingly stood in line behind Audie Murphy and Bill Gates
- but not Obama or Sanders.