America's Affordable Health Choices Act of 2009 - The USCHO debates

[St. Clown]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

Another primary care doctor weighing in on CNN.

http://www.cnn.com/2009/HEALTH/08/25/harris.primary.care.doctor/index.html

Health policy experts agree that any reform in our health care system must include a well-educated, caring primary care doctor who is able to manage the health of his or her patients with an eye to using resources optimally to keep costs down.

That's a tall order and it seems that few policy makers realize the value of primary care physicians.

People are making a huge assumption in this reform effort that as we extend coverage to millions who don't have health insurance, there will be doctors there to actually provide the health care. Fewer and fewer medical students are choosing primary care and many primary care doctors are leaving the field.

Let me share with you why we are losing so many primary care doctors. What follows are a few examples I experience each week.

Basically, he goes on to explain why even if this reform passes, the policy will fail without actual reform or the ability to lure more doctors to the relatively unsexy specialty of primary care. (Mentioning the "specialty of primary care," is that oxymoronic?)

Regardless of the finances, we're not ready or able to add more patients into the system for a large number of years without some severe rationing. That's the sort of rationing that the proponents claim will never happen within this new system.

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

St. Clown:

So the problem with this proposal is that supply will be trumped by demand? In the long term, won't the basic principles of a free market (supply/demand, etc) work out a solution to that problem on its own? And isn't that a notion that appeals to many of the kinds of people that would oppose Obama?

 

[MinnFan]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

St. Clown:

So the problem with this proposal is that supply will be trumped by demand? In the long term, won't the basic principles of a free market (supply/demand, etc) work out a solution to that problem on its own? And isn't that a notion that appeals to many of the kinds of people that would oppose Obama?

Except free market principles aren't in play unless you think that the bill will be re-written to allow doctors' salaries to skyrocket.

 

[Patman]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

That's the sort of rationing that the proponents claim will never happen within this new system.

you have to move with the arguments... now they say that anything is rationing by definition but that their rationing is in fact more moral.

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

Except free market principles aren't in play unless you think that the bill will be re-written to allow doctors' salaries to skyrocket.

Why would that be necessary?

Increased source of of patients with fewer doctors: doctors can charge more money. Doctors can charge more money: more doctors want to choose the field.

Since when did free market proponents insist that anything be legislated in order for it to work?

 

[MinnFan]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

Why would that be necessary?

Increased source of of patients with fewer doctors: doctors can charge more money. Doctors can charge more money: more doctors want to choose the field.

Since when did free market proponents insist that anything be legislated in order for it to work?

...costs go up. I thought the point of the bill was to bring costs down

Also, with re-imbursement capped at or below Medicare rates I don't think you'll see a flood of new doctors anytime soon.

 

[busterman62]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

St. Clown:

So the problem with this proposal is that supply will be trumped by demand? In the long term, won't the basic principles of a free market (supply/demand, etc) work out a solution to that problem on its own? And isn't that a notion that appeals to many of the kinds of people that would oppose Obama?

It might if it were truly a free market. Medicare pays a fixed amount for an office visit. All other insurers pay a percentage of that amount. Say 110% for really high end insurance and 70% for Medicaid. The Dr. can charge you whatever he/she wants for the visit, even $1M if they want, but unless you're paying cash, it will only be paid at predetermined rates. The rates for primary care are horrible for the time expended. The current system rewards a specialist much better than a primary care Dr. for doing the same thing. The Doc in the last article linked hit the nail on the head. Primary care is doing more for less and if the system is capitated, it's even worse.

Assuming that the current "reform" fixes this and actually pays primary care what they're worth (How many times have you heard that promised les? ), you're still looking at roughly 10 years before supply might rise enough to come close enough to meet the demand.

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

...costs go up. I thought the point of the bill was to bring costs down

Also, with re-imbursement capped at or below Medicare rates I don't think you'll see a flood of new doctors anytime soon.

The point of the bill is to introduce a new insurance option. One more player in the insurance field means more competition. That's the driving principle to keep costs down. More options means companies have to either charge less or offer more to compete. If a new, privately held company comes around and wants to offer that to the public... are we going to debate it at all? Why does it make a difference who sponsors a new program?

What this discussion is turning into is how to encourage doctors to choose primary care while keeping costs down. While the whole "doctors need people to pay them, and people need help to cover medical bills" thing connects the two, insurance and health care are otherwise seperate entities.

 

[leswp1]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

It might if it were truly a free market. Medicare pays a fixed amount for an office visit. All other insurers pay a percentage of that amount. Say 110% for really high end insurance and 70% for Medicaid. The Dr. can charge you whatever he/she wants for the visit, even $1M if they want, but unless you're paying cash, it will only be paid at predetermined rates. The rates for primary care are horrible for the time expended. The current system rewards a specialist much better than a primary care Dr. for doing the same thing. The Doc in the last article linked hit the nail on the head. Primary care is doing more for less and if the system is capitated, it's even worse.

Assuming that the current "reform" fixes this and actually pays primary care what they're worth (How many times have you heard that promised les? ), you're still looking at roughly 10 years before supply might rise enough to come close enough to meet the demand.

Actually rarely. They say they should do it but the lobby for the specialists is so strong the primary care folk are like the poor stepchildren.
I believe the current stat is 9% of med students are chosing primary care.

Capitation is frightening. It means even more of your time for less $. If I was a medically complex patient I would be very afraid of that system in the current insurance scenario.

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

It might if it were truly a free market. Medicare pays a fixed amount for an office visit. All other insurers pay a percentage of that amount. Say 110% for really high end insurance and 70% for Medicaid. The Dr. can charge you whatever he/she wants for the visit, even $1M if they want, but unless you're paying cash, it will only be paid at predetermined rates. The rates for primary care are horrible for the time expended. The current system rewards a specialist much better than a primary care Dr. for doing the same thing. The Doc in the last article linked hit the nail on the head. Primary care is doing more for less and if the system is capitated, it's even worse.

Assuming that the current "reform" fixes this and actually pays primary care what they're worth (How many times have you heard that promised les? ), you're still looking at roughly 10 years before supply might rise enough to come close enough to meet the demand.

But you don't argue that supply would eventually have to meet a high demand?

And this whole notion that we can somehow force Primary care into being a better field is absurd. You can't legislate which profession people go into. You can't legislate whether the public is willing to invest more of their money into primary care. They'll either go to their primary physician or they won't. But you can't sit there and pretend that, without an increased pool of patients (such as through having increased competition among insurance agencies, which- as a principle- will offer more to both patients and doctors), that there's any way to pay primary doctors more by paying them less. X equals Y times Z. If you want to increase X, and decrease Z, you need to increase Y. Simple math.

 

[MinnFan]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

The point of the bill is to introduce a new insurance option. One more player in the insurance field means more competition. That's the driving principle to keep costs down. More options means companies have to either charge less or offer more to compete. If a new, privately held company comes around and wants to offer that to the public... are we going to debate it at all? Why does it make a difference who sponsors a new program?

Its not competition when one entity can work at a loss indefinitely.

Profit is the driving principle to keep costs down. The lower you can get your costs the higher both your profit margin and market share can be. Without profit there is no competiton. Nobody (except the gov't) is going to start a business to lose money. Without profit there can be no new capital to help the business be more efficient.

 

[ScoobyDoo]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

Its not competition when one entity can work at a loss indefinitely.

Profit is the driving principle to keep costs down. The lower you can get your costs the higher both your profit margin and market share can be. Without profit there is no competiton. Nobody (except the gov't) is going to start a business to lose money. Without profit there can be no new capital to help the business be more efficient.

So, we should eliminate the public school option? How about State Colleges, let's eliminate those too.

In other words, your argument isn't holding water.

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

Its not competition when one entity can work at a loss indefinitely.

Profit is the driving principle to keep costs down. The lower you can get your costs the higher both your profit margin and market share can be. Without profit there is no competiton. Nobody (except the gov't) is going to start a business to lose money. Without profit there can be no new capital to help the business be more efficient.

The government option will not be set to be efficient. That's a given.

The government option will potentially bleed money. Not garaunteed, but is certainly a reasonable possibility.

Let's assume for a second that the government loses money. It takes less money in from the public than it gives out to doctors in insurance payments. That money that they pay out has to go somewhere, doesn't it? Like the conservation of energy (hey, I'm an engineer...), that money doesn't just disappear. It goes to the health care providers (whomever that entails, depending on the service provided). Meanwhile, the consumer- in theory- pays less money. The government eats the loss, because they'll never pay back any debt that they have. Who loses there? The doctors get their money and profit. The consumers pay less.

The only loser in that scenario is, potentially, rival insurance agencies. I can buy that argument. They cannot compete with the government, so they may have to operate "lean". Well... whatever lean means to them, I've a feeling that doesn't look quite the same as running lean for the rest of us. However, if the impetus for this action is that the doctors and patients are getting the short end of the stick from the insurance companies... why would we complain about that result?

 

[ExileOnDaytonStreet]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

So, we should eliminate the public school option? How about State Colleges, let's eliminate those too.

In other words, your argument isn't holding water.

Ha... wholly privatize education... now that's a laugh.

Get your diploma, sponsored by 3M!

But that's a whole different argument to be had the next time someone brings up the idea of government-funded private school vouchers.

 

[leswp1]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

http://www.wbur.org/news/npr/112172939

Link to an interview re public medical systems. Some of the systems had very inovative ideas. The Swiss story was particularly interesting.

 

[busterman62]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

But you don't argue that supply would eventually have to meet a high demand?

Quite the opposite. Regardless of the demand, until it becomes at least as financially attractive to enter into a primary care field as it is to enter into a specialty, the supply of primary care providers will continue to diminish.

And this whole notion that we can somehow force Primary care into being a better field is absurd. You can't legislate which profession people go into. You can't legislate whether the public is willing to invest more of their money into primary care. They'll either go to their primary physician or they won't. But you can't sit there and pretend that, without an increased pool of patients (such as through having increased competition among insurance agencies, which- as a principle- will offer more to both patients and doctors), that there's any way to pay primary doctors more by paying them less. X equals Y times Z. If you want to increase X, and decrease Z, you need to increase Y. Simple math.

Let me start by saying that the phrase "simple math" probably shouldn't be used in any discussion concerning healthcare.

I apologize for getting a little lost with your reply. I'm assuming that in your example you're saying that the increase in the number of patients available to be seen will allow (or at least offset) the low reimbursement and allow the Dr. to increase (or at least maintain) current income. Most PCPs I know are already maxed on how many they can see. (You can fit in 3-5 more a day, right les?) You need more PCPs now so what's going to happen when there's more patients? You think a PCP whose already maxed out is going to just see more at a rate that's set below what they're getting now? (really les, you can fit a few more in ) Make it viable to go into primary care and more med students will choose it. Make it more attractive to go into a sub-specialty and more med students will choose it. While the Gov't can't (at least at this time) legislate what field med students choose, they most certainly improve the primary care supply by making it more attractive financially. Don't do it and watch the current trend continue. Do it and the supply of PCPs increases and the "gatekeeper" model (if backed up by tort reform) should lower costs.

 

[Bill]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

So, we should eliminate the public school option? How about State Colleges, let's eliminate those too.

In other words, your argument isn't holding water.

You surely don't think private health insurance companies can compete for long with a government option that doesn't have to make a profit and is supported by the government's ability to print however much money it needs to run the show?

 

[Kepler]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

The provision of public defenders for the indigent sure has driven down the fees lawyers charge.

 

[Handyman]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

This might be stupid but I know that there are reliefs and breaks set up in education to persuade incoming teachers to work in the inner-city or in low income areas. My buddy does that and he gets a significant portion of his federal debt wiped away if he stays at his school for 5 years. Could the government not do the same thing (with or without this bill that isnt my point) to try and get med students to become PCPs? I mean I don't know if it will work I know nothing about what it takes to become a specialists vs. a PCP but wouldnt that be a good way to open the door at first?

 

[Kepler]

Re: America's Affordable Health Choices Act of 2009 - The USCHO debates

That would be government investment and government investment is always bad. Except when it isn't (farm subsidies, corporate R&D subsidies, financial sector bailouts, DOD development programs). I would think that would be clear by now.

Government investment directed to people who don't need it: wise policy.
Government investment directed to people who need it: socialism.