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View Diary: ACA's narrow networks allow insurance companies to gouge public, doctors (97 comments)

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  •  Yes, docs are compensated by frequency of (6+ / 0-)

    visits and diagnosis and not by quality of such.  Single payer won't fix that - instead it will institutionalize graft.

    "The way to see by faith is to shut the eye of reason." - Thomas Paine

    by shrike on Sun Nov 24, 2013 at 03:12:13 PM PST

    [ Parent ]

    •  Why are per capita costs so much lower (8+ / 0-)

      in countries with a single-payer system, then?

      •  Because those countries put limits (11+ / 0-)

        on care -- the whole "rationing" argument.  In other words, in this country, when you have an 80 year old with a significant medical condition, and he could either die or a $100,000 medical condition has a 20% chance of extending his life 3 months, most families demand that care (they want the doctors to "try everything"), and there's typically not a panel to say, "that's a hugely expensive procedure for an outcome that has less than a 1 in four chance of being successful, and success is only a short increase in his life, not a cure, so it's not financially worth it."

        Also, some expensive elective procedures which simply increase quality of life near the end of life may be denied to certain patients.  

        We do a little choosing of who will get what care under what circumstances (who gets heart transplants is literally a life and death decision, since there aren't enough donor hearts to meet demand).  But in cases where the government has more control over medical care, more of those kinds of decisions are made.  The ACA sets up the IPAB which can do some of that kind of thing (by setting extremely low Medicare reimbursements for disfavored treatments, for example), which is why Republicans called it a "death panel."

        The majority of medical spending is for care at the end of life.  Countries that control medical spending have to get control over those expenditures.  Culturally, the U.S. is not accustomed to being told, "there's a last chance procedure that has a 1 in 10 chance of keeping Grandma alive, but because it has a low outcome Medicare won't pay for it."  

        •  Ah, so if conservatives don't like something (6+ / 0-)

          we should just give up on it. Cool. I'll just go throw the EPA, Social Security, and the 8 hour workday in the garbage then.

          Don't be daft. There's no difference between your "death panel" or the "market" when it comes to granting care. Denial from either one still kills your grandma.

          The difference is, you're not going to get equality or justice out of a market. You are likely to get your pocket picked, though.

          •  Your mistake: (3+ / 0-)
            Don't be daft. There's no difference between your "death panel" or the "market"
            But Medicare has no price controls now so therefore that model is unsustainable on a general basis.

            "The way to see by faith is to shut the eye of reason." - Thomas Paine

            by shrike on Sun Nov 24, 2013 at 03:51:25 PM PST

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          •  I was talking about Medicare (3+ / 0-)
            Recommended by:
            VClib, nextstep, Pi Li

            which is not "the market," but is a single payer system.  

            That's why Medicare, as currently constituted, is completely unsustainable.  See the latest Medicare Trustees Report, pdf here.

            •  Medical cost curve is changing dramatically (6+ / 0-)
              Recommended by:
              quill, Tonedevil, myboo, ybruti, worldlotus, JesseCW

              That report, constrained by law to do simple projections, is already out of date. The projection that Medicare would eat the economy were always unrealistic, but now they are completely absurd:

              Medical cost curve shifting

              Fear-mongering about the unsustainability if Social Security and Medicare was fairly mainstream a few years back, but facts don't support it.

              Promoting the need to "reform" (meaning cut) Social Security and Medicare does not seem like a Progressive Democratic position.

              •  Don't be fooled by short-term numbers. (3+ / 0-)
                Recommended by:
                Pi Li, Roadbed Guy, howarddream

                Yes, the 2013 report showed a short-term improvement, if you read it.  The date it becomes insolvent was extended a year or two.  But it showed long-term unsustainability, even considering the cost cutting in the ACA.  The 2013 Report said that if Congress never again did the "doc fix," things were just unsustainable.  If Congress did the "doc fix" (which everyone assumes they will), the long term outlook is horrible.  

                The very point that you pointed out  -- the better short term outlook -- was addressed by the Medicare Trustees in an article that you can find reprinted here.

                Here's what the Medicare Trustees say about that:

                There is no reason to believe that the recent reported slowdown in health care cost growth will improve the long-term picture significantly relative to current projections. At our press conference announcing the release of the trustees’ report, I was surprised to hear questions asking in effect whether a recent slowdown in health care cost growth might have a significant effect on the outlook and debate surrounding the Medicare program. To my ear the questions reflected an incomplete understanding of the factors underlying current projections. It would be mistaken to conclude that the recent slowdown in health care cost growth (partially though not wholly attributable to the recent recession) should relax pressure for much-needed Medicare reforms.

                It’s important to understand that our long-term projections already assumed a substantial slowdown in health care cost growth relative to historical rates. This is because the projections are based on demonstrated trends in the elasticity of health care cost growth – in layman’s terms, how much people’s health care consumption patterns change as a result of factors that include health care prices, income levels, and insurance coverage. To put it more crudely, we have never expected that historical rates of health care cost growth will continue to the point where health care services absorb our entire economy. We are not going to have a society in which we are all walking around homeless, naked and starving but with impeccable health care.

                Thus even before the 2010 passage of the ACA, we were assuming that health care cost growth would eventually slow down. Adding the ACA’s aggressive Medicare cost restraints to that assumption means that we are in effect assuming over the long term that Medicare expenses will actually grow more slowly per capita than our general economy. This assumption is one reason why many have questioned whether the ACA’s cost restraints will be sustainable over the long term. At the very most, one might argue that the recent slowdown in health care costs renders current projections slightly more plausible, but no one should be assuming that things are going to look much better.

                It's not the rosy picture that some want to make it out to be.  

                And I'm not trying to be "progressive Democratic" or "conservative Republican."  I'm reporting the facts, as outlined by the Medicare Trustees.  Anyone who is interested in actual facts should look at the full Trustees Report.  

                We'll see when the 2014 Trustees Report comes out this spring.  

              •  The DailyKos far right travels in a pack and (2+ / 0-)
                Recommended by:
                Urban Owl, priceman

                is utterly immune to logic.  They are opposed to most of the party platform.

                There's really no point to trying to reason with them.  They do not share our goals. They participate here with the sole objective of attempting to forestall progress on issues ranging from a living wage to the right to organize to protecting social security to banking regulation to health insurance reform.

                They're always  on message, and never on our side.

                "I read New republic and Nation/I've learned to take every view.." P. Ochs

                by JesseCW on Mon Nov 25, 2013 at 05:24:31 AM PST

                [ Parent ]

            •  No, it's really not. (3+ / 0-)
              Recommended by:
              Chi, JesseCW, aliasalias
              That's why Medicare, as currently constituted, is completely unsustainable.
              Once we take money from the MIC and drones and wars and NSA spying and computers.
            •  Medicare isn't too expensive, America's private (4+ / 0-)

              for profit healthcare system is too expensive. Everything Medicare or private insurance buys, from aspirin to heart transplants, costs more here than in other country in the world.

        •  money doesn't need to be rationed (3+ / 0-)
          Recommended by:
          gooderservice, Chi, Pi Li

          A government sovereign in its own currency can print whatever amount of money it needs to.

          Doctors and health care professionals need to be rationed, medicines and technology need to be rationed. Those are real resources, they are finite, and they have to be managed carefully so that they aren't squandered and are directed with maximum effect.

          But money is not a resource, it is just a way of keeping score. You can't run out.

          You don't need to "control spending" as such under a single-payer program. You might have to control costs--maybe it's not desirable for other reasons to allow companies to charge too-high a price for medicines and technology--but not because you need to limit spending.

          The real question is not whether it's too expensive to approve a certain procedure for Grandma, that's a red herring. The question is whether it's a smart use of limited resources (medicine, tech, doctors, nurses, hospital beds) that could go to other patients who might have a better chance of making it if those resources were used to treat them.

          Antibiotic resistance is a classic dilemma of this type. Every use of an antibiotic on one patient decreases its effectiveness for other patients because it increases the chance of antibiotic-resistant bacteria.

          So when you're faced with a very sick older patient who probably won't live too much longer even if you cure him/her, should you use the powerful antibiotic and risk creating a strain of antibiotic-resistant bacteria that could kill or sicken many younger patients with a longer life expectancy?

          These are very hard decisions, much harder than trying to limit spending. Harder to quantify what the risks are and how care should be rationed. To weigh the abstract possibility of future patients dying from an antibiotic-resistant germ against the immediate and concrete certainty of a dying patient now is very difficult.

          "In America, the law is king." --Thomas Paine

          by limpidglass on Sun Nov 24, 2013 at 04:09:52 PM PST

          [ Parent ]

        •  End of Life care is not the cost driver (7+ / 0-)

          You assert that the differences in healthcare costs per capita are due to differences in end of life care, but cite nothing to back that up.

          A recent PBS interview with Harvard's David Cutler lists 3 reasons for Americans paying more for healthcare, and your story about other countries just letting grandma die isn't on the list.

          Why American healthcare costs so much

      •  Clever Handle - because we practice medicine (5+ / 0-)

        in a completely different manner than any other country in the world. The reason that our costs per capital are 2X the other countries in the G8 isn't because of a lack of single payer, or because insurance companies take too big a cut, or that we don't let the federal government negotiate with drug companies, or have a fee for service system, or even that our healthcare professionals earn more. Changing all of those things would help some, but they aren't the big reason we spend more, yet have poorer outcomes. In the US we teach and practice medicine in a manner unlike any other country in the world, even the other highly developed first world countries in the G8. If we want to move our cost per capita to be more in line with the rest of the G8 we would need to start teaching a different way of practicing medicine in our medical schools, and even then it would take a generation for a different way to practice medicine to become the new standard of care.

        If you entered a healthcare facility in New York or London complaining of chest pain the protocol for the diagnosis and treatment of your chest pain would be radically different. That's why our healthcare costs so much more.

        "let's talk about that"

        by VClib on Sun Nov 24, 2013 at 04:04:03 PM PST

        [ Parent ]

        •  That sounds vague and spurious (5+ / 0-)

          What exactly about the way we teach medicine results in higher costs?

          •  One thing is the students end (1+ / 0-)
            Recommended by:

            up loaded with massive debt, which is then used to justify much higher salaries (both compared to other countries, and the "massive" debt incurred in their education . . .).

          •  CH - I have been involved in healtcare for (0+ / 0-)

            nearly 30 years both in the US and Europe. If our mythical patient with chest pains presented at a hospital or clinic each attending physician would pull down a computer screen with a check list and a suggested diagnostic and treatment path. The one in London would be different from the one in New York. It would obviously have some overlap, but they are different in a fundamental way.

            "let's talk about that"

            by VClib on Sun Nov 24, 2013 at 06:04:27 PM PST

            [ Parent ]

            •  Okay. (2+ / 0-)
              Recommended by:
              JesseCW, aliasalias

              1) How are they different? How does that difference result in higher costs?
              2) How big of a cost increase does it cause?
              2) Why will this take a "generation" to undue? Can't you just change what comes up on that computer screen? Why will the doctor have to unlearn and relearn all the medical knowledge they learned at medical school?

              •  You can't just change what is on the computer (5+ / 0-)

                screen because what is on the New York screen is the standard of care for US physicians and patients. The London screen has been shaped by decades of policy and experience of the NHS. For our New York physician to deviate from the US standard of care requires him/her to expose themselves to professional and legal risks. The US standard of care is the result of hundreds of peer reviewed articles and a consensus of the various US medical societies.

                In the UK, and the rest of Europe, they have developed a standard of care that involves less technology, particularly less expensive technology and more observation and touch and feel by the physician. In the US it's easier using high tech diagnostics to reach a conclusion quicker. It's also more expensive. In terms of therapy the UK and EU will do less intensive and invasive cardiac procedures in the cath lab for a patient with the same systems. And per capital they use fewer stents and perform less open heart surgery. In the last fifty years the practice of medicine in the UK and EU have been structured to be very cost efficient. Budgets for the single payer systems are always under political pressure and it significantly influences how medicine is practiced. At times it may put the patient at more risk, and not be as satisfying as in the US, but it costs a lot less.

                So that's why it is a hard problem to solve. These are procedures and protocols developed over many decades and engrained into the teaching curriculum of the medical schools in the US and those in Europe. There is no easy fix.

                "let's talk about that"

                by VClib on Sun Nov 24, 2013 at 07:43:35 PM PST

                [ Parent ]

                •  It seems like this description is (1+ / 0-)
                  Recommended by:

                  consistent with what I posted above (or somewheres in these nested threads) about how the fault of the US system in making it very expensive is that it is overly procedure based.

                  It seems like that's pretty much exactly what you're saying here.

        •  I suggest writing a diary about your ideas (0+ / 0-)

          so we can see and discuss the changes you recommend.

          •  I am not sure it's possible to change (1+ / 0-)
            Recommended by:
            Roadbed Guy

            The way we practice medicine here is something that has developed over the last half century. It is so ingrained into the culture of medicine I don't know if it can be changed. And if it could be changed it would take a generation to implement.

            To do a really thoughtful job would take a major effort. I don't really have the time and doubt people would really care, so it's hard to put in the effort. I may retire some time in 2014 and if I did I'd have the time to write diaries on topics like this.

            "let's talk about that"

            by VClib on Sun Nov 24, 2013 at 06:00:24 PM PST

            [ Parent ]

            •  what about Canada? I lived there for years (0+ / 0-)

              my son and two daughters were born there and have always lived there, so I've seen a lot of the difference between the US of $ and Canada.

              One of my grandsons will need physical therapy for long time and last night speaking with one of my daughters she told me about her recent health issues. All of which she attended to by getting an appointment and seeing a couple of doctors...all of that was done without her ever once having to think about money.
              This side of the border they wouldn't be paying monthly mortgage payments to keep their lovely home, that money would all be going to some insurance company for them to dole out to health care people.

              without the ants the rainforest dies

              by aliasalias on Mon Nov 25, 2013 at 11:50:26 AM PST

              [ Parent ]

              •  aliasalias - I am not defending the US system (0+ / 0-)

                just trying to help people understand why change would be so difficult and that the difference in cost isn't because of single payer versus fee for service.

                Canada represents a good model for the US, but even if we adopted it tomorrow it would not solve the reason why healthcare in the US is so much more expensive than the EU.

                "let's talk about that"

                by VClib on Mon Nov 25, 2013 at 02:30:34 PM PST

                [ Parent ]

      •  They are lower just about everywhere (1+ / 0-)
        Recommended by:

        And even in the US, the components of our health care system that are single-payer (Medicare, Medicaid, VA) also have per capita costs higher than other countries.

        "Well, I'm sure I'd feel much worse if I weren't under such heavy sedation..."--David St. Hubbins

        by Old Left Good Left on Sun Nov 24, 2013 at 04:32:31 PM PST

        [ Parent ]

    •  only if you think that a Medicare for All (7+ / 0-)

      program would not have rules about what services will and won't be compensated and safeguards against fraud. I don't think anyone is proposing the government simply pay for every service anyone requests from a doctor.

      Right now undercare, caused by insurers wanting to hold on to every single dollar of insurance premiums, is a bigger problem than overcare, caused by doctors charging for extra services in order to line their pockets. Many doctors are specialists anyhow who make their money off of rich old (often white male) patients who pay cash.

      Although of course the fee-for-service model must be reformed to avoid physician abuses.

      Suggesting that we need private insurers because we need gatekeepers to do triage rather misses the point. They have no interest in a sensible rationing of health care, only in grabbing every single dime. If they had their druthers, they'd ration care by denying it to everyone. They're coming pretty damn close to that already.

      I would much rather have a democratically accountable government organization performing this triage function, rather than private, for-profit entities.

      "In America, the law is king." --Thomas Paine

      by limpidglass on Sun Nov 24, 2013 at 03:47:39 PM PST

      [ Parent ]

      •  Reasonable reply. In general I believe docs (0+ / 0-)

        are driven by high cost treatment but you provide for reform in that regard.

        "The way to see by faith is to shut the eye of reason." - Thomas Paine

        by shrike on Sun Nov 24, 2013 at 03:56:06 PM PST

        [ Parent ]

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