[jdonn]

axman, on Feb 26 2010, 04:37 PM, said:

I watched a man named Barrack Obama on TV yesterday.  He says that America’s biggest problem is that too many Americans don’t have health insurance.  He spent the time twisting the arms of various powerful men.  But what is plain to me is that he doesn’t have the faintest idea as to what his actual problem is; and should he achieve what he has set out to do, well, I’ll put it this way.  The real problem is that too many have health insurance, and of they who do, too many of them have not paid enough for it.

(Stolen from other thread, and bold mine)

Um... what?? I guess there are two questions. What makes you think you would know so well what the real problem is, assuming there even is "a" "real" problem? And why in the world would that be it?

[luke warm]

PassedOut, on Feb 26 2010, 09:45 AM, said:

kenberg, on Feb 26 2010, 07:20 AM, said:

I am not really happy about how things are going with the reform effort. I guess I have mostly said why already,  but the brief version is that I think there are two problems, access and total cost, and the Dems have shown little interest in addressing the second. Of course the Reps have shown little interest in addressing the first. Oh well, what else is new?

I recorded the healthcare summit that Obama and the congressional leadership of both parties had at Blair House yesterday, then watched it in the evening~~

excellent summary... a few other things that could help... we all know that rx drugs are a major part of health costs, and yearly increases... i attended a (long) meeting today on this, and we decided to implement a policy whereby if there is a generic equivalent, then one must get it... this means that the generic does not have to be of the name brand prescribed, it can be a generic of an 'equivalent' drug... assume for example that prozac and xanax are prescribed for the same problem and that there is no generic for prozac but there is for xanax... if the doctor writes a script for prozac, you must get the generic for xanax... there would have to be a good excuse why you can't take that particular generic before this requirement is relaxed

the above would be for max benefits... if you still chose to get the prozac, you would pay the difference between the cost of the prozac and the generic cost of the xanax equivalent

i like obama's idea re: tort reform, depending on exactly how far it goes (max award, etc)... as for consumer protection standards, i'd like to know what's meant by this... is there an example of a state that allows a company to set low or no such standards? if so, where and what company and what exactly are that company's practices that make them substandard?

the pooling of risk is interesting insofar as standard practice is to actuarially set risk-rated premiums for a set period of time, 1 or 2 years for example... these premiums would tend to be higher for that initial period of time, and i can see where some sort of subsidy would be needed... but i agree that the bigger the pool the less the premiums... healthy and sick have to blend for insurance to be available to all... i think the 2014 obama limit is reasonable, assuming the overall health of the population improves... i'd prefer a longer time period to maintain the subsidy, say 2020

as for the MA plans, i'd always assumed they would be gone within the next 2 years in any case... they seem to work well and most seniors who have them seem to like them, except for the drug plans... the trouble is, CMS has rules in place of which most seniors have no idea... for example, if i have a group MA plan and at some point decide that i want to buy an individual drug plan (to help with costs), CMS will term my MA plan... that's just one of many rules they have... all in all, i believe obama is correct that removing this subsidy, assuming the money is funneled back into health care, is not actually cutting medicare

[mike777]

I read reports that the cost may come to 2 trillion not one trillion over the next 10 years.


It may be cheaper and with less government intrusion if we just offer to pay health insurance for those too poor to afford it.


If many of the 30 million uninsured cannot afford insurance and they want insurance lets buy it for them.


Then try for a bit of tort reform, insurance across state lines in a separate bill and that sounds like a good first step.

[kenberg]

I read the report in The Atalntic and I guess I wasn't convinced. I think back over the involvement I have had with medical care and I really cannot see how the costs of any of it would be reduced by the elements in the bill. The costs will be shifted, possibly there will be some slowing of the rate of growth, any better than that would surprise me.

One thing occurred to me while reading: We have often been told that the ordinary guy should be entitled to health care that is equal to that received by our Senators. We are also told that the Cadillac plans that unions love are a big part of the problem Can I infer from this that the union worker has a much better plan than members of the Senate? Or will they also be taxing the plans of the members of the Senate? I assume the answer to the last question is no, but I am truly curious about the first question. How good are these Cadillac plans? Better than what the Senate provides for its members?

[PassedOut]

luke warm, on Feb 26 2010, 06:34 PM, said:

i attended a (long) meeting today on this, and we decided to implement a policy whereby if there is a generic equivalent, then one must get it... this means that the generic does not have to be of the name brand prescribed, it can be a generic of an 'equivalent' drug... assume for example that prozac and xanax are prescribed for the same problem and that there is no generic for prozac but there is for xanax... if the doctor writes a script for prozac, you must get the generic for xanax... there would have to be a good excuse why you can't take that particular generic before this requirement is relaxed

I agree completely with this approach.

[PassedOut]

kenberg, on Feb 26 2010, 08:11 PM, said:

I read the report in The Atalntic and I guess I wasn't convinced. I think back over the involvement I have had with medical care and I really cannot see how the costs of any of it would be reduced by the elements in the bill. The costs will be shifted, possibly there will be some slowing of the rate of growth, any better than that would surprise me.

The ideas seem a reasonable starting point to me and will surely begin to cut costs. It seems to me that they specifically address problems you've related in these forums, such as unnecessary prescriptions and procedures.

I'd like to see more aggression along the same lines, and I do wish some republicans had supported the bill in exchange for more certain tort reform. But I'm truly interested in what you would consider to be more effective ways of reducing costs, and how you would assess their chances of passage.

[kenberg]

How to do it I am not sure. But I am not the president so it's ok.

I often try to run abstract ideas past my own experience.

I. A couple of years back I go to the emergency room with chest pains. After 24 hours or so it is becoming clear it is not my heart. Ah, but there is another test they can do. Not at this hoopsital though. It's Saturday, they will do it Monday.l OK, I'll check out and go get the test Monday. No way. I will stay at the hospital two more nights and then be taken by ambulance to the other hospital.
Could I insit? maybe, but what's my motivation. It wouold mark me as an uncooperative patient and the cost to me of two more days in the hospital and an amulance trip for an almost certainly unneeded examination is zero dollars. So I'll read a book.

II. I got a rash that won't go away. I see the doc, he refers me to a dermatologist who asks if I have prescription insurance. Yes. He can recommend an OTC lotion that will cost maybe $20, or he can write a prescription (refillable and refilled) for a $250 lotion which will cost me nothing.Which would I prefer? Duh, let me think.

I don't have many examples because my health has been good. But there seems to be zero motivation for anyone to watch the bottom line at all. There are some vague notions iin the bill about cutting out waste. The devil is in the details, as they say.

Try eating in downtown DC. It's expensive. Why? Why not? Many of the meals are paid for by influence peddlers. If a lobbyist comes back to his boss and tells him how much money he saved by taking a senator to a modestly priced restaurant he gets fired. If costs are to be held down, someone has to have a strong interest in accomplishing this on a day to day basis.

There are just so many tricks. I know I told this before but in the case of the cream for my rash here is what happened. Actually there was a co-pay. But I didn't pay it. The manufacturer took a cream that he wanted to sell for $200, marked it up to $250, and gave a coupon to get a $50 discount. The discount covered the co-pay. Actually it more than covered it, so maybe I was entitled to a cash incentive for using this stuff.


Small potatoes, sure. But I doubt my experience is unique, and in many cases the potatoes are much larger.

On many things I try to take it easy. I was in San Francisco last month and even though a grant was picking up the tab I chose a hotel with reasonable rates. But on health, if the tab on the high priced option is taken care of, I guess I will choose that one. As will everyone. This is not the way to keep costs down.

Costs will go down when and if the consumer has to make some contribution to the bill. The poor need to be helped, I understand that. But everyone needs to be motivated to try to save a little on expenses. I don't see that happening.

[PassedOut]

Reimbursements for treatment are going to shift away from paying for everything ordered to those treatments that actually produce results. If useless procedures and medications aren't reimbursed, I expect that fewer will be ordered.

[mike777]

PassedOut, on Feb 27 2010, 12:11 AM, said:

Reimbursements for treatment are going to shift away from paying for everything ordered to those treatments that actually produce results. If useless procedures and medications aren't reimbursed, I expect that fewer will be ordered.

I hope this is just the kind of issue the government stays out of...


but your suggestion raises the issue to the very heart.

I mean do free capital markets want to reimburse for useless procedures and useless medications.......I hope the answer is NO

this kind of gets back to my thread....do free capital markets want to make reckless loans?

BAsed on the post responses the answer seems to be Yes...Yes they do

[PassedOut]

mike777, on Feb 27 2010, 12:17 AM, said:

I mean do free capital markets want to reimburse for useless procedures and useless medications.......I hope the answer is NO

People who are paid for every procedure, useless or not, order many procedures. That is the current situation. So the answer today is YES.

Do you suppose that the FDA should stop testing drugs because no company would want to sell useless or dangerous drugs on the free market?

How about testing meat? Wouldn't meat be cheaper if companies didn't have to worry about those damned government inspections? Surely no company would want to sell bad meat in a free market. Or would they?

[mike777]

PassedOut, on Feb 27 2010, 12:30 AM, said:

mike777, on Feb 27 2010, 12:17 AM, said:

I mean do free capital markets want to reimburse for useless procedures and useless medications.......I hope the answer is NO

People who are paid for every procedure, useless or not, order many procedures. That is the current situation. So the answer today is YES

so if this is "bad" should not free capital markets adjust?

For instance.......tort reform to stop "defensive medicine"....no tort reform.....more def...med.

If not tort reform...we, the insurance companies jack up rates more and more and more......

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


my point being the answer is not.....no tort reform but more price controls....more government in health care.

[kenberg]

PassedOut, on Feb 27 2010, 12:11 AM, said:

Reimbursements for treatment are going to shift away from paying for everything ordered to those treatments that actually produce results. If useless procedures and medications aren't reimbursed, I expect that fewer will be ordered.

So they tell me. I'm not from Missouri but still.

It's not going to be so easy judging what is a useless treatment. After all, I'm still alive so who is to say the treatment I received was useless? I suppose the extra tests might ahve found something. Eventually the cause of the pain was diagnosed, nothing to do with the heart. The ointment that the dermatologist gave me cleared up my rash. Not useless.

Here is a more emotional variation. We had a Black Lab during his puppyhood. After a year or so he was to go off to guide dog school to learn his skills. Unfortunately he had bad legs and could not handle the work, so the guide dog folks asked if we wanted him back Sure! No regrets at all, but this free dog cost somewhere in the neighborhood of $20,000 in vet bills during his life. As he got to be around 12 or 13, his legs were givning out once again. We kept him comfortable until it got too bad, then we put him down. OK, dogs and humans are different. But I know I am going to die someday and as I understand it about half of a person's lifetime total of medical expenses are in the last year. If at some future point I am told that well, we could keep you alive for another month but it will cost a lot, your wife will have nothing left, there will be nothing to leave the kids, I am quite confident of my ability to say "We are done here". Unless someone else will pay for it, of course. That's a different story.


I hope that the savings will materialize. I remain a skeptic.

[PassedOut]

kenberg, on Feb 27 2010, 06:45 AM, said:

If at some future point I am told that well, we could keep you alive for another month but it will cost a lot, your wife will have nothing left, there will be nothing to leave the kids, I am quite confident of my ability to say "We are done here".

I'm right with you on this, and those hugely expensive end-of-life measures need to be treated as unacceptable waste. People who want such measures should have to pay for them individually, or else buy insurance policies on their own for specific coverage.

I would have much preferred this issue to have been addressed directly in the proposed legislation, but there was not so much as a mention of this in the Thursday conference. The republicans have backed away from their earlier proposals in this regard, under pressure from the wing-nuts.

But if you look at the legislation, you will see that a mechanism exists that will inevitably cause such necessary judgments to be made, one that will insulate elected representatives from the political fallout stirred up by those wing-nuts yelling about death panels. I'm disappointed that the current proposal is not better than it is, but I get that most politicians are timid, fearful people.

Flaws in legislation get fixed over time, like the Medicare part D donut hole. When I play a bridge hand and one plan is certain to fail, I try to find a different plan that has at least some chance to succeed. The health care situation in the US today is in the "certain to fail" category.

[kenberg]

Flaws may get fixed over time, but the scale is often huge. Back in the 80s or so, I assume no senator actually got up and said "I have a great idea. Let's write the tax code so that if a couple who are living in sin decide to get married it will cost them a couple of extra thousand in taxes." But it wasn't so long ago I was listening to Robert Reich speaking on NPR about how it would just be too difficult and expensive to fix it. My guess is that when this gets put through, what we see is what we get for quite a while.

No one addressed these end of life issues because it is made ot order for demagogues. What, you want to kill off someone's grandmother? Heartless, heartless. But people make health decisions all the time based on cost, at least when they have to pay part of the bill. I belong to the YMCA. I like it. There is an athletic center (aka gym) near me with individual membership fees that are higher than the Y's family rate. And that's out here in the sticks. If someone else wants to pick up the fees, I bet I could find a really classy place.

Anyway, we will be getting something. It will not be all that it's advocates claim, that never happens. Perhaps it will be eventually seen as a plus. That would be satisfactory. I have no ideological objection to doing some good in the world.

[Winstonm]

Doesn't a healthcare system based on a profit model cause a multiplier effect on costs?