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  • FlagDUDE08
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by DrDemento View Post
    Interesting point-i would love for someone to post a relaible source for a number which shows what percentage of money is spent on medical care going to the doctor providing the care versus the percentage that is spent on medical care that goes for the administration of care. I think a number of people would be surprised to see those figures.
    You said that, around 2000 or so, it was 1:2, yes? I'm not saying your office is a model for the entire country, of course...

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  • FlagDUDE08
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by DrDemento View Post
    Rover-The population expansion has of course a lot to do with everything. Limit the population growth and the cost of medical care would certainly fall. But there has also been an explosion in the number of providers (not all of them physicians but even if you simply counted MDs the numbers are far greater). The government's thought process went something like this--increase the number of doctors and that introduces competition which causes prices to fall. WRONG. Every doctor, and now every provider of any sort, wants to make a living-and they all see as many patients as possible and do as many tests as they can which of course INCREASES the cost of care. As i mentioned-i have no quick fix. In fact I am not sure I have even a slow fix. Unless someone wants to bite the bullet and simply say 320 million people is enough to take care of.
    Perhaps this is why we see/hear those "Questions are the Answer" PSAs when it comes to health care? I know you've heard it a few times during the intermissions of RPI hockey games; you couldn't have been THAT plastered.

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  • FreshFish
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by DrDemento View Post
    In another post I asked the query-is medical care a right? Is food a right? Is housing a right?
    While I don't have the answers, I do notice that, in the Declaration of Independence and in the US Constitution, all but one of the rights are to intangible things: freedom of speech, of religion, of assembly, the right to vote, protection against cruel and unusual punishment, to be tried by a jury of one's peers, etc.

    There is only one right to a tangible, physical good in the US Constitution, and that is the right to own a gun.


    Personally, I think this is a reflection of the wisdom of our Founders. How can you possibly guarantee people the right to food if there is a drought? Right to housing if there is a tornado or hurricane? with any physical good there is potential scarcity. Society needs to figure out how to allocate resources on its own without the government stepping in and picking one method over another, at least in the US that I love. If you want guaranteed security, move to a country that promises it; but be prepared for a lower standard of living as a direct result of that promise.

    The poorest people in the US today are better off than all but the richest people in many other parts of the world. We lose perspective sometimes. Who wants to be a millionaire in Syria or Iran these days?

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  • DrDemento
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by FlagDUDE08 View Post
    The point that is trying to be made is that, given the same number of patients, more administration is needed in today's world. Therefore the cost of business to cover just the administrative costs, given you have to pay these administrators, has trebled to quadrupled. Granted the bottom line hasn't necessarily risen by this factor because the physician's labour rate hasn't changed (although any associated products cost may change), but you probably get the point.

    However, I would not put all of this on insurance companies, because that's been an effective wash since the 40's. The biggest culprit is the government regulation, because at least one of those administrators is required to ensure compliance. Tack onto that a monopoly created by the government called Medicare. I call it a monopoly because, in order to receive Social Security retirement funds, you must be enrolled in Medicare. I won't go through the rest of the details again as it'll practically turn into talking points; just look earlier in the thread.
    Interesting point-i would love for someone to post a relaible source for a number which shows what percentage of money is spent on medical care going to the doctor providing the care versus the percentage that is spent on medical care that goes for the administration of care. I think a number of people would be surprised to see those figures.

    Leave a comment:


  • DrDemento
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by Rover View Post
    Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.
    Rover-The population expansion has of course a lot to do with everything. Limit the population growth and the cost of medical care would certainly fall. But there has also been an explosion in the number of providers (not all of them physicians but even if you simply counted MDs the numbers are far greater). The government's thought process went something like this--increase the number of doctors and that introduces competition which causes prices to fall. WRONG. Every doctor, and now every provider of any sort, wants to make a living-and they all see as many patients as possible and do as many tests as they can which of course INCREASES the cost of care. As i mentioned-i have no quick fix. In fact I am not sure I have even a slow fix. Unless someone wants to bite the bullet and simply say 320 million people is enough to take care of.

    Leave a comment:


  • DrDemento
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Brooky-There is a lot more to it. I used to spend 65 hours per week seeing patients. I hated to go home. Jenny ran my office and we detested Sundays because we had to wait until monday to get back to work. By the time we closed the office (and the major reason we did close) i was seeing patients for about 20 hours per week and spending 40 hours per week either on the phone with Medicare/Insurance carriers or dealing with the mail from Medicare/Insurance carriers. As you might guess, I am a very compulsive physician. I still love doing what i do and certainly wish it could be the way it was.

    Les: I wish we had a simple solution but since the government has been so involved in determining what is the best way to provide medical care for the population for the last 50+ years, there is no quick fix. They have had enough time to screw things up royally. They use all sorts of worthless statistics to pass rules and regulations that simply make the system more cumbersome, more chances for fraud and abuse (by providers and patients alike), and unwieldy. If anyone out there right now thinks that they are getting the best and most attentive medical care please raise your hand. In the government's attempt to contain medical costs they have just introduced more and more types of providers (whether scientifically proven and valid or not) into the equation to take a slice of the medical money pie. In another post I asked the query-is medical care a right? Is food a right? Is housing a right? With the follow up-then is everyone entitled to the same medical care, food and housing? If not-are we entitled to a minimum standard of food, housing and medical care? And who defines what that minimum is? These are basic questions that need to be addressed before we can make any valid attempt to manage the cost of medical care. Obviously i do not know the answers. I simply know from numerous personal anecdotal examples i could give-that I have been restricted from giving the best medical care and the best advice and medications by people who have never set foot in a medical school or even treated a patient. We seem to be on the same page-but with a slightly different perspective. I am no longer as active in the practice but i still do consultaion work-totally gratis. I have not charged for medical care or advice in 11 years. I sometimes wish i could just sit back and relax and do nothing-but i love what i do far too much and the feeling of providing help for someone was the absolute number 1 reason I went into the field.

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  • FlagDUDE08
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by Rover View Post
    Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.
    I can understand your concepts, but once again, execution falls flat. OK, so there's a government reimbursement plan. Decent concept. Could costs be higher? Sure; just look at my last post for a few reasons. The only problem is the government only has so much money to cover those reimbursements. I don't think I need to tell you what happens when you run the press. Could you keep taxing the rich? You could, but what happens when they either run out of money or expatriate? You decide to set specific rates for reimbursement, or price ceilings. Practitioners decide not to participate. Then, you put in legislation to force them to participate. They decide to retire because it isn't worth the cost. If you need an explanation as to what happens then, look at ANY urban gas station in the mid-to-late 70's. Instead of strengthening health care, you're actually destroying the supply.

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  • FreshFish
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by Rover View Post
    I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments?
    That's a relatively small part of the equation, at least based on my experience, though of course I'll defer to those with more current direct everyday contact with the system.

    > You have mandated coverages whether the insured even wants them or not (e.g., I think NY State requires every individual plan to cover chiropractic; at one time you could get a plan that would not cover "routine" maternity although it would cover both the newborn and also any complications of pregnancy).
    > at one time you'd have separate coverage for "major medical" and "hospitalization" so that you could get each one from a different insurer if you wanted; now everything is all rolled up into one whether you want it that way or not
    > Much of the care that once had been provided through charitable entities is now being paid for by government instead (not quite the same as what you said and also related to it)
    > You have mandatory benefit minimums and deductible maximums (it used to be cheaper to get one plan with a benefit cap and then another really high deductible plan with no benefit cap; you can't do that any more).
    > Indirectly, you sometimes have state laws that tilt the outcome of tort cases one way or another.

    And of course, you have the aftermath of WWII wage-price controls that still leave tremendous pricing distortion in their wake. Just imagine how different it would be if, starting in 1946, everyone bought coverage in the individual market and no one received coverage as part of their employment benefit package!


    Finally, there is a very important distinction between saying "(excess) government involvement increases the expense" compared to saying "all the increase is due to the government." I'd say, roughly, that there are four main components:
    > unintended consequences due to well-intentioned yet poorly-thought-out government "meddling" (okay pick a different term if you want, you get my drift, see above)
    > improvements in quality (you'd expect to pay more for a better product, no?)
    > improved longevity. Like the brain teaser about the British army introducing new gear for the soldiers, and head injuries increased by 2,000%, and they were absolutely delighted! Things that once killed people now can be cured, which means those people then subsequently receive additional care they never would have received otherwise (the most extreme example of course would be reductions in infant mortality rates). this factor then feeds into the two above so you get synergistic effects.
    > people don't see their total bill. if I ran an insurance company, I'd make sure people saw the entire bill for everything, including what the insurance company paid for (weird that our dental insurance works that way but not our health insurance). People think they are getting something for next to nothing and so overuse the system's resources compared to how they would behave if they themselves had primary responsiblity to pay for it.
    Last edited by FreshFish; 10-26-2012, 12:37 PM.

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  • FlagDUDE08
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by brookyone View Post
    Wouldn't that be a somewhat normal progression with a growing practice? Isn't that the objective of a private practice...more patients? I understand administrative / clerical has become far more cumbersome. Ridiculously so in many instances. That's pretty standard with any business. I have pretty extensive experience in claims administration in a few other industries outside of medical. A commonality is whomever is ultimately paying claims establishes policy & procedure for those providing services which involve claims for reimbursement. It isn't just the health services industry that are required to navigate an intense, constantly changing maze of requirements or procedures set by the entity paying the claims. Just like health insurance companies...the goal is to withhold that payment as long as possible and deny reimbursement per failure to cross any T or dot any I. For the record...I think it's been established we can point the finger at health insurance companies as a culprit per this thread topic and probably acknowledge that was the case well before healthcare legislation. Or so I've gathered from les...whose experiences and frustration remind me a great deal of a former similar administrative position I had.
    The point that is trying to be made is that, given the same number of patients, more administration is needed in today's world. Therefore the cost of business to cover just the administrative costs, given you have to pay these administrators, has trebled to quadrupled. Granted the bottom line hasn't necessarily risen by this factor because the physician's labour rate hasn't changed (although any associated products cost may change), but you probably get the point.

    However, I would not put all of this on insurance companies, because that's been an effective wash since the 40's. The biggest culprit is the government regulation, because at least one of those administrators is required to ensure compliance. Tack onto that a monopoly created by the government called Medicare. I call it a monopoly because, in order to receive Social Security retirement funds, you must be enrolled in Medicare. I won't go through the rest of the details again as it'll practically turn into talking points; just look earlier in the thread.

    Leave a comment:


  • Rover
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.

    Leave a comment:


  • brookyone
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by SJHovey View Post
    A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.
    Wouldn't that be a somewhat normal progression with a growing practice? Isn't that the objective of a private practice...more patients? I understand administrative / clerical has become far more cumbersome. Ridiculously so in many instances. That's pretty standard with any business. I have pretty extensive experience in claims administration in a few other industries outside of medical. A commonality is whomever is ultimately paying claims establishes policy & procedure for those providing services which involve claims for reimbursement. It isn't just the health services industry that are required to navigate an intense, constantly changing maze of requirements or procedures set by the entity paying the claims. Just like health insurance companies...the goal is to withhold that payment as long as possible and deny reimbursement per failure to cross any T or dot any I. For the record...I think it's been established we can point the finger at health insurance companies as a culprit per this thread topic and probably acknowledge that was the case well before healthcare legislation. Or so I've gathered from les...whose experiences and frustration remind me a great deal of a former similar administrative position I had.

    Leave a comment:


  • SJHovey
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by DrDemento View Post
    edit-It has been stuff like this that added reasons to my desire to semi retire. The bigger reasons though as I mentioned were government and insurance company control and interference with our ability to provide the best care for everyone.
    A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.

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  • FreshFish
    replied
    Re: The Sad Case of the Patient Protection and Affordable Care Act

    Originally posted by brookyone View Post
    Requirements for things like continuous coverage under prior group plan. COBRA benefits you can't come close to affording.
    You hit the nail on the head, so to speak. One of the single biggest problems we have today is over-reliance on employer-sponsored group health insurance plans.

    Ironically, this outcome is a direct result of prior government meddling that should be a cautionary tale, yet somehow, whenever well-intentioned yet poorly-thought-out government meddling creates unintended consequences, the so-called "solution" always seems to be increased government meddling!

    During WWII, about 25% of the domestic economic production was for military purposes (and the private sector did a fantastic patriotic job of organizing itself, by the way: kudos to FDR for setting aside his typical statist impulses to request voluntary cooperation instead: it produced far better results! ). The problem: 100% of the money was still here. That created tremendous inflationary pressure.

    The government response: wage and price controls (there was an entire gov't department dedicated to it, with checklists and inspectors and everything). Since companies were prohibited from increasing wages, they resorted to offering expanded fringe benefit packages (tax deductible, naturally) to retain and reward their employees. Naturally, once the war ended, this distortion remained behind.

    It's not at all difficult to envision how an economy-wide individual insurance pool priced at group rates with periodic "open enrollment" windows would replicate the same outcome without the distortions caused by the disparity of treatment between "self-employed / in transition" with "employed by someone else." The Federal employees' health insurance program works like this already, and many state government employees' health insurance programs also work this way.

    So if we already have an example of how this can operate, and both the employees and employers are happy with the result, why not merely replicate this success on a broader scale?

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  • FlagDUDE08
    replied
    Re: A system that doesn't want to change

    Originally posted by leswp1 View Post
    You may have been through tough times but obviously not something insurmountable. Not every situation has a solution because you have the fortitude to try hard to overcome it or have the right attitude. That is only in the fairy tales. There are some situations that do not have solutions and the lack of solution is life altering/threatening. To imply otherwise is not particularly realistic.
    When did I say anything about a solution? Look, anyone who thinks there's a solution to everything is naïve. What I said was that what defines you is what you do with the situation. That doesn't mean to solve it.

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  • FreshFish
    replied
    Re: A system that doesn't want to change

    Originally posted by leswp1 View Post
    Over the years I ... am seeing more of the people who do have their priorities in the right place but financially are unable.
    For about a year, I worked as an office assistant to an attorney who specialized in pre-packaged bankruptcy filings. The single biggest cause of personal bankruptcy back then was uninsured medical bills.


    Originally posted by leswp1 View Post
    When things were all private insurance or self pay the repetoire of what could be offered as far as meds and intervention was limited compared to now and from what I can remember were not as expensive. Early in my career our office reduced rates/ got veggies/fruit etc or bartered in some way with those in need. We had samples of meds that we could give and the pharm co had ways to access for those in need altho that was not predictable. Patients could apply for free care at the hospital for tests and admission but that did not wave the cost of the other Docs etc. The complexity of care was certainly much less. If you had a stroke/MI no one put something in your vessel to rotorouter a clot or repair an aneurysm. Many of the things that would kill you or at least leave you very incapacitated now have treatments that are quite expensive either with pharmaceuticals or intervention but are considered standard.
    yes, this is a very concrete example that illustrates just how myopic and foolish it is to say that increases in health care costs above the rate of inflation is somehow a "problem." We are getting more in increased value in return for what we pay; ask anyone who today gets arthroscopic surgery compared to the scar that was left behind 25 years ago from knee surgery and they'll tell you that quality and value are better today relative to the cost than it was then!!


    Originally posted by leswp1 View Post
    When I started practice things were in place so I do not know what it was like before the safety net. I remember the change the 80/20 to the HMO concept but that came very early on. I can't envision a way that could consistantly provide care to people in need with the current cost of care if there was no net. The net seems to work for those in poverty but fails abysmally here for the working 'poor'. The patients I see who can't afford care would be significantly more stable and probably less costly if they lived somewhere with socialized medicine.

    If we were to revert to a completely private system how would that work? If you could revamp things how would you? I would love to hear your opinion.
    (seriously asked)
    Again, I'm not attributing the "myopia" to you but to general social perceptions: there has never been a completely private system ever, and so there would be no "reversion" to it. To me the true question is what is the "proper" level of involvement of government relative to other parts of society. Look at Catholic Charities for example, or the Mormon Church, or Aid Association for Lutherans, or any of the other non-governmental, non-private sources of assistance. It seems pretty clear to me as an observer close to the front lines for nearly 35 years that increased government involvement leads to increased difficulties, not fewer. Of course that is not to say that government has no role whatsoever; that's merely a tired old trope that the "progressives" trot out whenever people say they've "gone too far": they try to pretend that the only alternatives are either their latest intrusion into heretofore private space, or nothing at all.

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