The Sad Case of the Patient Protection and Affordable Care Act

[leswp1]

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

You pretty much have summed up my feelings very well also. I never have tolerated decisions being made for me-and especially resisted when it involved my medical decisions for anyone (my patients, my family, myself). I also particulary dislike when these items become political footballs and the popular press reporting one stupid poll after another about how this group or that group feels. The most disturbing of all however, is when they try to justify making these decisions for us based on some sort of statistical or scientific basis-when we all know that it is simply about the bottom line and the dollar.

There needs to be a like button on here

[DrDemento]

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

In both abortion and the asst suicide thing I have strong personal opinions but those are my opinions. I don't want someone else having the right to tell me what I can do with my body when the decision is life changing. I don't think anyone should have the right to make my decisions.

You pretty much have summed up my feelings very well also. I never have tolerated decisions being made for me-and especially resisted when it involved my medical decisions for anyone (my patients, my family, myself). I also particulary dislike when these items become political footballs and the popular press reporting one stupid poll after another about how this group or that group feels. The most disturbing of all however, is when they try to justify making these decisions for us based on some sort of statistical or scientific basis-when we all know that it is simply about the bottom line and the dollar.

[leswp1]

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

Les

My thoughts
1. Even the Globe seems to be against the proposed Mass. law on assisted suicide. IIRC, they think its poorly written (at least somebody read it)
2,3 & 4 -- No problem with discussions on end of life care. Some may say, keep me fed and watered and comfortable and let nature take its course. Others want to prolong their life as long as possible. That's their decision, and as long as they can afford it, no problem. When they can't, back to fed, watered, and comfortable and let nature take its course.
5. -- It can be - who is doing the counseling and do they have an agenda?
6. -- No problem. Don't hide the truth. Doc #1 did that to my Dad. Doc #2 told him he had 2 weeks to live (that's about what he lasted).
7. -- they are, but religion cannot be removed from the public square, otherwise we may end up with Germany in the 30's.
8. -- If all PP did was birth control, I'd hold my nose and look the other way. But I will not fund their abortion activities.
9. -- Kids are jumping into bed with each other waaayyyyy too early and for all the wrong reasons. Why? Is the culture to blame where the sex act is being treated as just another biological function and not something more?
10. Yes. Aren't we all???

My point is we are very conflicted in our views not that I am sure what is right. People hold views but do not think about what the fallout of those views can be. Example- Clinic in local HS dispensed BC and did education regarding prevention of pregnancy. Rates of pregnancy went way down. The numbers were astounding in a fairly short period of time. Funding was cut to these programs to 'balance the budget' and because there were those who weren't in agreement that govt should fund this type of venture. Rates went up significantly. This had the unintended affect of costing a lot of cash because a) the pregnancy medical costs b)the baby has medical costs c) mother can't afford daycare so can't work. This funding was eventually restored but not at the previous level and the numbers decreased again. We can argue all we want about the principle of the thing but the reality is that there are young people who have sex no matter what we think about the morality. That costs MONEY. We don't want to provide educationbecause of cost and morality but that is proven to decrease early sex .

THe PP thing leaves me conflicted- I would prefer no abortions were ever needed. I have a hard time with people who feel it is OK in certain circumstances and not in others- if you think it is murder it is no matter whether rape is involved or not. (the guy being lambasted in the press right now is probably the least hypocritical of us all). As a society we do nothing to make sure these babies or their mothers have a chance at success- that is all left up to serendipity and usually that means the young mother is doomed a poor economic situation and her kid is at a disadvantage.

The asst suicide ads right now are beyond irritating. I could understand argument on moral cause but these ads are very misleading. It makes it sound like the person can walk into the pharm and score seconol on a whim. It also says families dwon't be involved at all. Well- from what I understand it isn't a quick process to get OK'd for the drug. The person should have the personal liberty to make the decision regardless of whether we would make the decision differently. In a perfect situation the family should be involved but they shouldn't have any say in the final decision. I find it the implication that those counseling regarding end of life would have ulterior motives disturbing. In my experience the problem is the inability to discuss things realistically/folks not having the gonads to tell patients they are in a bad way rather thn them trying to get people to forgo care. All the studies show people who chose the palliative care after a good discussion end up with a better outcome as far as outlasting expectations and having better quality of life.

In both abortion and the asst suicide thing I have strong personal opinions but those are my opinions. I don't want someone else having the right to tell me what I can do with my body when the decision is life changing. I don't think anyone should have the right to make my decisions.

[joecct]

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

We actively work to ban assisted suicide (Mass currently has an initiative re: assisted suicide)
We are upset when the end of life care costs large sums of money
We do not want people to be paid to discuss what options people have regarding end of life
We expect people to figure out how to navigate the system and to make informed decisions regarding end of life care
We are afraid end of life discussions are a way to decrease cost to system
We do not want to hear about the studies that show people do better medically when they have those discussions
We want church and state to be separate.
We want to cut funding to Planned Parenthood/clinics that provide care to those who are economically challenged because we do not believe birth control is what God wants
We do not want to fund education programs that teach prevention of pregnancy because kids should be abstinent
We are frustrated when young women get pregnant before marriage.

Les

My thoughts
1. Even the Globe seems to be against the proposed Mass. law on assisted suicide. IIRC, they think its poorly written (at least somebody read it)
2,3 & 4 -- No problem with discussions on end of life care. Some may say, keep me fed and watered and comfortable and let nature take its course. Others want to prolong their life as long as possible. That's their decision, and as long as they can afford it, no problem. When they can't, back to fed, watered, and comfortable and let nature take its course.
5. -- It can be - who is doing the counseling and do they have an agenda?
6. -- No problem. Don't hide the truth. Doc #1 did that to my Dad. Doc #2 told him he had 2 weeks to live (that's about what he lasted).
7. -- they are, but religion cannot be removed from the public square, otherwise we may end up with Germany in the 30's.
8. -- If all PP did was birth control, I'd hold my nose and look the other way. But I will not fund their abortion activities.
9. -- Kids are jumping into bed with each other waaayyyyy too early and for all the wrong reasons. Why? Is the culture to blame where the sex act is being treated as just another biological function and not something more?
10. Yes. Aren't we all???

[leswp1]

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

We want to contain medical costs.
We think it is Ok for insurance companies to pay people who do not have advanced medical degrees to make decisions regarding what will be covered.
We are offended when it is suggested that a team of medical experts make general recommendations regarding care for certain diagnoses
We declare people sshould have personal freedoms to make decisions regarding medical care.
We complain that end of life care costs too much
We do not think it is OK for the patient to have an advance directive that says they should not get care or the family can decline further treatment
We have people who go to court to forbid withdrawal of life support systems for those outside their family
We want to ban assisted suicide.

We actively work to ban assisted suicide (Mass currently has an initiative re: assisted suicide)
We are upset when the end of life care costs large sums of money
We do not want people to be paid to discuss what options people have regarding end of life
We expect people to figure out how to navigate the system and to make informed decisions regarding end of life care
We are afraid end of life discussions are a way to decrease cost to system
We do not want to hear about the studies that show people do better medically when they have those discussions
We want church and state to be separate.
We want to cut funding to Planned Parenthood/clinics that provide care to those who are economically challenged because we do not believe birth control is what God wants
We do not want to fund education programs that teach prevention of pregnancy because kids should be abstinent
We are frustrated when young women get pregnant before marriage.

[FreshFish]

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

Remember how "getting coverage for people with pre-existing conditions" was supposed to be a major rationale for this unprecedented experiment in hubris?

How's that going so far?

The Affordable Care Act established a federally funded risk pool—the Pre-Existing Condition Insurance Plan—that allows individuals with such disqualifying conditions to buy a policy for the same premium a healthy person would pay. About 82,000 people have signed up as of July 31, according to the Kaiser Family Foundation's statehealthfacts.org.

That is not a misprint. Out of a population of more than 300 million, some 82,000 have the problem that was cited as the principal reason for spending $1.8 trillion over the next 10 years and in the process [author's editorial aside].

[FreshFish]

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

Life throws curve balls. It happens. How you react to those curve balls is what develops character.

"what doesn't kill us, makes us stronger"
-- naive idealist

"what doesn't kill us, maims us for life"
-- reality

[leswp1]

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

Trying to please everyone is unrealistic. It gets us into the mess we're in now. This is why I don't like let's-be-friends centrists or people who put their emotions ahead of their brains. You don't think it's realistic because you're too wrapped up in your feelings. I think don't work don't eat is absolutely perfect. Maybe with that, people in this country will once again have some character about them.

Life throws curve balls. It happens. How you react to those curve balls is what develops character.

THis sort of response sounds wonderful if you were a politician, would play to the those wide of the center and be absolutely impossible to pass into law. Taking any sort of emotion out of it, no matter how much you want to play hard ball the general public does not have the stomach to follow through. At least half the population would be diametrically opposed to this and the in the rest you wouldn't find enough to get anywhere.

THanks FF and joect for the thoughtful responses. I really wish the politicians were not so focused on the reactionaries in the respective parties and could use the some of those solutions.

2cents- I would salary everyone. Too much incentive to do too much or get penalized if you care for the patient instead of the insurance company.

[FlagDUDE08]

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

It seems to me that you are being unrealistic here. Some people are born with genetic defects...would you perform infanticide on them? Some people suffer debilitating injuries through no fault of their own, would you just let them starve?

"The perfect is the enemy of the good."

-- someone famous, I suppose....

Life throws curve balls. It happens. How you react to those curve balls is what develops character.

[FreshFish]

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

Trying to please everyone is unrealistic. It gets us into the mess we're in now. This is why I don't like let's-be-friends centrists or people who put their emotions ahead of their brains. You don't think it's realistic because you're too wrapped up in your feelings. I think don't work don't eat is absolutely perfect. Maybe with that, people in this country will once again have some character about them.

It seems to me that you are being unrealistic here. Some people are born with genetic defects...would you perform infanticide on them? Some people suffer debilitating injuries through no fault of their own, would you just let them starve?

"The perfect is the enemy of the good."

-- someone famous, I suppose....

[brookyone]

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

Trying to please everyone is unrealistic. It gets us into the mess we're in now. This is why I don't like let's-be-friends centrists or people who put their emotions ahead of their brains. You don't think it's realistic because you're too wrapped up in your feelings.

Or "too wrapped up" in common sense.

Wrong gender guess per your rep BTW. I buy my contraception devices at the drugstore.

[joecct]

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

FreshFish -- most federales have more than 3 health plans to choose from. Here in MD, I have (I think) 10+ all with various options. But the concept is there and why not open the FEHBA to the nation??

[DrDemento]

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

Back at you. You are singing my song. When I started in practice it was a calling. As an NP I make way less money than if I stayed on the floor (I make about 1/3 of what I could've if I stayed in house as a floor nurse). Until very recently the satisfaction of making a difference was more than enough to compensate for the $ and time. Now the needs way outweigh what I can do to help.

Things have changed on both sides of the table.

Even without all the insurance changes most of the 'Providers', nurses and medical staff we have coming out now want to have a job that is like a McDonald's shift. They don't want to take call, are proud they know how to set limits and will tell you they don't 'own it' (sadly they don't connect 'it' with a person, only the inconvienience), they want to work certain hours and they think like cookie cutters because they document in a system that discourages anything that doesn't fit into a little bubble in the computer window.

It seems people who feel they are owed care way outnumber those who are grateful when you go the extra mile. Before we would see people who gave us vegetables and had a pre-arranged payment plan. Now we go out of our way to work something out, people sign the plan and it means nothing. They say "I am sick, you have to see me, I don't care if I owe 800$. You can't deny me care!! I will report you" (Sadly we hear this a lot lately)

dxmmkd316 posted about waiting to get an appt until they knew they needed it. I wish more people thought like that. People seem to have lost the skill for self care and commonsense to take care of themselves or family members. It is like a massive dumbing down. Not much critical thinking. I am continually baffled and astonishing that people who are in financial duress are insistant they need an appt spending 25-50$ to see me if they vomit once or have a sniffle. They think if they come we have some sort of magic even when we try to tell them coming in will net them the same advice we will give over the phone. Many of these people come in for the exact same complaint and get teh exact same advice over and over. My MA keeps telling me to suck it up and collect the copay but I think it is a huge waste of resources and $.

Right on the button. Many years ago we had a fellow come in with a large facial skin cancer. Jenny explained what it would cost but he said he had no money and no insurance. We did the excision and repair anyway. Told him that we would treat him the same as everyone else who paid-on one condition. That he did not go around advertising that we treated him for free since i was sure everyone else would come in and ask for the same consideration. He owned a chicken farm-and about 3 weeks later he showed up at the office with 6 dozen eggs for me. He did not have to, but he felt better doing it. When we got home we found that he had hand candled them and selected only double yolk eggs for us. Best freakin omelets we have ever had! The fellow sent me so many other patients we lost count. In those days no one demanded anything from us and most everyone appreciated what we did and how we did it.

[FlagDUDE08]

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

Theoretically this is great. Pragmatically this is not going to happen. There are people who want to forbid abortion and but enough that don't agree that it isn't law. You aren't going to find too many people who would be OK with a law that lets people die who can look them in the face even if the medical establishment bought in.

What realistic plan can you come up with? They do not let people die because they can't pay. What do you do to the people who have nothing? You remove the safety nets and that just gets you a ton of people who come in with multiple co-morbidities in a medical mess that costs us more.

Trying to please everyone is unrealistic. It gets us into the mess we're in now. This is why I don't like let's-be-friends centrists or people who put their emotions ahead of their brains. You don't think it's realistic because you're too wrapped up in your feelings. I think don't work don't eat is absolutely perfect. Maybe with that, people in this country will once again have some character about them.

[FreshFish]

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

Many thanks to Mrs. Les, Dr. D, and dxmnkd316 (and joecct now) for their thoughtful, passionate, articulate, heartfelt comments!

I "get to" read trade journals and am able to learn about various practice models and trade practices from different states around the country, and here are a few "best practices" from various parts of the country that we could expand upon and learn from:

> idea: put MDs on salary instead of compensate them based on fee for service: see Kaiser Permanente in CA for example. MDs and staff can concentrate totally on serving the patients properly and well.

> idea: involve patients in billing audits: some insurance companies ask patients to double-check their hospital bills and give them a financial incentive to report mistakes ("hey, I see a charge here for a medication I was never given"). It is amazing the difference in results that occurs when patients actually see their total bill!!

> idea: promote wellness and preventive care: some insurance companies give a financial incentive to exercise: go to the gym three times a week for six months and get $100; or actually take the medicine prescribed by your doctor and receive lower insurance rates.

> idea: look at what works: the Federal employee health insurance program: they have [at least] three insurance companies [if not more] compete to sign up potential insureds; to deal with "pre-existing conditions" they have open-enrollment windows.

> idea: liberalize Section 125 Flexible Spending Account rules to allow people to roll over unused funds from one year to the next (the savings are worth the tax "cost", you myopic political types!!), which allows people over time gradually to "self-insure" by increasing their deductibles / sign up for a higher coinsurance option (and it also allows people during their working years to accumulate funds to pay for inevitably higher healthcare costs during retirement). You can still tax whatever's left when they die (though a spousal rollover would be nice!).

> idea: create a specialized court system for medical malpractice cases (similar to how bankruptcy cases, or tax disputes, or patent law disputes, or trademark infringement cases, all have specialized courts), so that people who understand the issues and have the experience and knowledge to assess the claims clearly and fairly (some physician groups have created self-insured malpractice insurance companies; they know who the risky ones are and keep them out, thereby lowering their malpractice insurance premiums substantially).

> idea: charge higher rates for unhealthy behaviors: it is not unusual for smokers to be charged a higher premium than non-smokers, for example....might we extend this concept? charge the morbidly obese more than people who are "merely" overweight? (it's already legal and widely accepted in life insurance in all US jurisdictions)


These are some of many examples that illustrate why, until this bill, insurance regulation was exclusively a state prerogative: because the people and situations across this great nation are so varied, it is essential to allow each state to tweak the rules to fit their own unique circumstances (although allowing interstate sales of a stripped-down "basic" policy might be nice too, as long as the features were standardized....)



While the existing law has myriad breakdowns, the biggest one of all is that the math doesn't add up. Accounting 101: inflows must equal outflows (i.e., if a=b then b=a). However, by statute, the law tries to enforce inflows < outflows. that can never work. It reminds me of the (perhaps apocryphal) story of the Indiana state legislature attempting to change the value of pi by statute...fortunately for them that law was voted down after engineers testified that if the value of pi were to be changed all the bridges in the state would collapse. At least in that case they listened to the professional experts and did not pretend to be smarter than everyone else!

There are plenty of innovative ways to address the failures and breakdowns described; it is truly a shame that none of them made it into this bill.