Discussion:
Seven Ways to Reduce Unnecessary Medical Costs --Right Now
(too old to reply)
Gary
2009-09-13 01:08:25 UTC
Permalink
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.

I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.

Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.

Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.

Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.

Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.

So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?

An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.

1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.

2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.

3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.

4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.

5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.

6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.

7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.

Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."

Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.

Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.

This article was posted on August 13, 2009.

http://www.insurancereformwatch.org/proposals/lundberg.shtml
Islander
2009-09-13 02:15:45 UTC
Permalink
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.

Frankly, I'm surprised that the insurance industry is not supporting
comparative effectiveness. Perhaps they have simply lost control of
their mobs.
Matthew Scott
2009-09-13 06:27:14 UTC
Permalink
Islander wrote:
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will determine which procedure government insurance will PAY for, not "that the best treatments can be selected". This is precisely how NICE functions in the UK. Yet another decision taken away from doctor/patient to be made by the centralized bureaucrats. Will it happen immediately? Obviously not. Will it, in time, result in de facto rationing? Certainly.
Josh Rosenbluth
2009-09-13 11:09:10 UTC
Permalink
Post by Matthew Scott
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from doctor/patient
to be made by the centralized bureaucrats. Will it happen immediately?
Obviously not. Will it, in time, result in de facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a government
or private-insurance bureaucrat.
Matthew Scott
2009-09-13 15:07:33 UTC
Permalink
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a government
or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the private contract before it is signed, or if he/she doesn't like it, walk away; not so with government funded health care, which is what the discussion was about. And if a consumer deems it important to be covered, for say, sex change operations, or dentistry, or optometry, or acupuncture, or whatever, there is an insurance company somewhere which will provide the desired coverage. Not so with government funded health care and comparative effectiveness studies.

It's fun to speculate about the 'unintended consequences' of ObamaCare. Given all the regulation in the works (community rating, guaranteed acceptance, prohibition of caps, etc) I wonder what the actuaries have to say on the matter. It sounds to me as if the insurance companies are going to be so tightly regulated that their autonomy will be questionable, and they will become nothing more than executors of government policy. It'll be interesting to see how many decide to stay in the business, long term.

I seriously doubt that Medicare as currently configured (Parts A & B) comply with ObamaCare's regulations. Wonder how they're gonna fix that little glitch.
Josh Rosenbluth
2009-09-13 15:52:18 UTC
Permalink
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
El Castor
2009-09-14 00:29:18 UTC
Permalink
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
Josh Rosenbluth
2009-09-14 00:57:05 UTC
Permalink
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
El Castor
2009-09-14 17:20:06 UTC
Permalink
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Rita
2009-09-14 17:42:23 UTC
Permalink
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
El Castor
2009-09-15 03:38:27 UTC
Permalink
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.

Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Rita
2009-09-15 03:57:30 UTC
Permalink
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.

But you know all that.
El Castor
2009-09-15 04:23:32 UTC
Permalink
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
Do what you want, but my wife and I like our current coverage and
would like to be left alone.

Oh -- one other thing. Obama did promise that whatever it is that you
folks do won't increase the deficit by as much as a dime. Didn't think
I had forgotten that, did you? Not a dime. (-8
Rumpelstiltskin
2009-09-15 14:37:39 UTC
Permalink
On Mon, 14 Sep 2009 21:23:32 -0700, El Castor <***@Here.Com> wrote:
<snip>
Post by El Castor
Do what you want, but my wife and I like our current coverage and
would like to be left alone.
As the famous saying goes "I've got mine, Jack".
It's less than nihilism, it's selfish-ism.

It's not entirely impossible that one day El Castor
could unexpectedly find himself on the other side.
I expect the tune would change if that happened,
although it would probably only change to "It's so
unfair that I ended up on the other side where it's
fair for people other than myself to be".
Post by El Castor
Oh -- one other thing. Obama did promise that whatever it is that you
folks do won't increase the deficit by as much as a dime. Didn't think
I had forgotten that, did you? Not a dime. (-8
El has forgotten how we got the debt we have,
as have all the Republicans.
Evelyn
2009-09-15 14:45:59 UTC
Permalink
Post by Rumpelstiltskin
<snip>
Post by El Castor
Do what you want, but my wife and I like our current coverage and
would like to be left alone.
As the famous saying goes "I've got mine, Jack".
It's less than nihilism, it's selfish-ism.
It's not entirely impossible that one day El Castor
could unexpectedly find himself on the other side.
I expect the tune would change if that happened,
although it would probably only change to "It's so
unfair that I ended up on the other side where it's
fair for people other than myself to be".
Post by El Castor
Oh -- one other thing. Obama did promise that whatever it is that you
folks do won't increase the deficit by as much as a dime. Didn't think
I had forgotten that, did you? Not a dime. (-8
El has forgotten how we got the debt we have,
as have all the Republicans.
So convenient for them to blame Obama for it all.......
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
El Castor
2009-09-15 16:25:00 UTC
Permalink
On Tue, 15 Sep 2009 07:37:39 -0700, Rumpelstiltskin
Post by Rumpelstiltskin
<snip>
Post by El Castor
Do what you want, but my wife and I like our current coverage and
would like to be left alone.
As the famous saying goes "I've got mine, Jack".
It's less than nihilism, it's selfish-ism.
It's not entirely impossible that one day El Castor
could unexpectedly find himself on the other side.
I expect the tune would change if that happened,
although it would probably only change to "It's so
unfair that I ended up on the other side where it's
fair for people other than myself to be".
Post by El Castor
Oh -- one other thing. Obama did promise that whatever it is that you
folks do won't increase the deficit by as much as a dime. Didn't think
I had forgotten that, did you? Not a dime. (-8
El has forgotten how we got the debt we have,
as have all the Republicans.
I haven't forgotten that in 2007 the Bush deficit was $165 billion,
and this year Obama will have increased it by more that 1,000% Did
that slip your mind?
Evelyn
2009-09-15 17:07:00 UTC
Permalink
Post by El Castor
On Tue, 15 Sep 2009 07:37:39 -0700, Rumpelstiltskin
Post by Rumpelstiltskin
<snip>
Post by El Castor
Do what you want, but my wife and I like our current coverage and
would like to be left alone.
As the famous saying goes "I've got mine, Jack".
It's less than nihilism, it's selfish-ism.
It's not entirely impossible that one day El Castor
could unexpectedly find himself on the other side.
I expect the tune would change if that happened,
although it would probably only change to "It's so
unfair that I ended up on the other side where it's
fair for people other than myself to be".
Post by El Castor
Oh -- one other thing. Obama did promise that whatever it is that you
folks do won't increase the deficit by as much as a dime. Didn't think
I had forgotten that, did you? Not a dime. (-8
El has forgotten how we got the debt we have,
as have all the Republicans.
I haven't forgotten that in 2007 the Bush deficit was $165 billion,
and this year Obama will have increased it by more that 1,000% Did
that slip your mind?
Apparently you forgot the Bank bailout etc. Those are NOT Obama's fault.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 20:31:27 UTC
Permalink
El Castor - yes, I think perhaps Rumple had a blackout - - since you are
correct about the deficit numbers - which Obama has increased over the
Bush numbers.
Olly
Allan
2009-09-15 12:41:16 UTC
Permalink
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all.  If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested.  Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.

That aside, Medicaid is there to take care of these situations - why
doesn't it?

allan
Jean Smith
2009-09-15 13:11:08 UTC
Permalink
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all.  If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested.  Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
That aside, Medicaid is there to take care of these situations - why
doesn't it?
allan
Because states see much of it as an unfunded requirement that they don't want to
assume.
--
C-SPAN http://www.c-spanarchives.org/#todaysEventsHeading
Check http://politifact.com http://healthcarefactcheck.com/
http://www.healthactionnow.org/?s_src=20090622_US_E_HAN_LaunchAT
Rita
2009-09-15 14:15:09 UTC
Permalink
Post by Jean Smith
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to
the
private contract before it is signed, or if he/she doesn't like it,
walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all.  If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested.  Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
That aside, Medicaid is there to take care of these situations - why
doesn't it?
allan
Because states see much of it as an unfunded requirement that they don't want to
assume.
You have to make yourself a pauper to qualify for Medicaid, a step
many middle class people who are faced with enormous medical costs are
reluctant to take -- it can mean giving up a job and any savings
you have managed. In order for it to serve the purpose Alan suggests
the income and asset limits to receive it would have to be
drastically increased.

And it is not only those who lose their jobs because they get sick
who are faced with medical bankruptcies.

This reminds me of the Scrooge "are there no poor houses" approach

"At this festive season of the year, Mr. Scrooge," said the
gentleman, taking up a pen, "it is more than usually desirable that we
should make some slight provision for the Poor and Destitute, who
suffer greatly at the present time. Many thousands are in want of
common necessaries; hundreds of thousands are in want of common
comforts, sir."

"Are there no prisons?" asked Scrooge.

"Plenty of prisons," said the gentleman, laying down the pen again.

"And the Union workhouses?" demanded Scrooge. "Are they still in
operation?"

"They are. Still," returned the gentleman, "I wish I could say they
were not."

"The Treadmill and the Poor Law are in full vigour, then?" said
Scrooge.

"Both very busy, sir."

"Oh! I was afraid, from what you said at first, that something had
occurred to stop them in their useful course," said Scrooge. "I'm
very glad to hear it."

"Under the impression that they scarcely furnish Christian cheer of
mind or body to the multitude," returned the gentleman, "a few of us
are endeavouring to raise a fund to buy the Poor some meat and drink
and means of warmth. We choose this time, because it is a time, of
all others, when Want is keenly felt, and Abundance rejoices. What
shall I put you down for?"

"Nothing!" Scrooge replied.

"You wish to be anonymous?"

"I wish to be left alone," said Scrooge. "Since you ask me what I
wish, gentlemen, that is my answer. I don't make merry myself at
Christmas and I can't afford to make idle people merry. I help to
support the establishments I have mentioned -- they cost enough; and
those who are badly off must go there."

"Many can't go there; and many would rather die."

"If they would rather die," said Scrooge, "they had better do it, and
decrease the surplus population. Besides -- excuse me -- I don't know
that."

"But you might know it," observed the gentleman.

"It's not my business," Scrooge returned. "It's enough for a man to
understand his own business, and not to interfere with other people's.
Mine occupies me constantly. Good afternoon, gentlemen!"
Evelyn
2009-09-15 14:41:33 UTC
Permalink
Post by Rita
In article
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that
the
best treatments can be selected. That is far more than (but
may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or
without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to
the
private contract before it is signed, or if he/she doesn't like it,
walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or
optometry,
or
acupuncture, or whatever, there is an insurance company
somewhere
which
will provide the desired coverage. Not so with government
funded
health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing
in
private insurance is based in large part on ability to pay. the
overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who
can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well to
do
to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
That aside, Medicaid is there to take care of these situations - why
doesn't it?
allan
Because states see much of it as an unfunded requirement that they don't want to
assume.
You have to make yourself a pauper to qualify for Medicaid, a step
many middle class people who are faced with enormous medical costs are
reluctant to take -- it can mean giving up a job and any savings
you have managed. In order for it to serve the purpose Alan suggests
the income and asset limits to receive it would have to be
drastically increased.
And it is not only those who lose their jobs because they get sick
who are faced with medical bankruptcies.
This reminds me of the Scrooge "are there no poor houses" approach
"At this festive season of the year, Mr. Scrooge," said the
gentleman, taking up a pen, "it is more than usually desirable that we
should make some slight provision for the Poor and Destitute, who
suffer greatly at the present time. Many thousands are in want of
common necessaries; hundreds of thousands are in want of common
comforts, sir."
"Are there no prisons?" asked Scrooge.
"Plenty of prisons," said the gentleman, laying down the pen again.
"And the Union workhouses?" demanded Scrooge. "Are they still in
operation?"
"They are. Still," returned the gentleman, "I wish I could say they
were not."
"The Treadmill and the Poor Law are in full vigour, then?" said
Scrooge.
"Both very busy, sir."
"Oh! I was afraid, from what you said at first, that something had
occurred to stop them in their useful course," said Scrooge. "I'm
very glad to hear it."
"Under the impression that they scarcely furnish Christian cheer of
mind or body to the multitude," returned the gentleman, "a few of us
are endeavouring to raise a fund to buy the Poor some meat and drink
and means of warmth. We choose this time, because it is a time, of
all others, when Want is keenly felt, and Abundance rejoices. What
shall I put you down for?"
"Nothing!" Scrooge replied.
"You wish to be anonymous?"
"I wish to be left alone," said Scrooge. "Since you ask me what I
wish, gentlemen, that is my answer. I don't make merry myself at
Christmas and I can't afford to make idle people merry. I help to
support the establishments I have mentioned -- they cost enough; and
those who are badly off must go there."
"Many can't go there; and many would rather die."
"If they would rather die," said Scrooge, "they had better do it, and
decrease the surplus population. Besides -- excuse me -- I don't know
that."
"But you might know it," observed the gentleman.
"It's not my business," Scrooge returned. "It's enough for a man to
understand his own business, and not to interfere with other people's.
Mine occupies me constantly. Good afternoon, gentlemen!"
Perfect description of the GOP way.........
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Allan
2009-09-15 20:34:25 UTC
Permalink
Post by Rita
Post by Jean Smith
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to
the
private contract before it is signed, or if he/she doesn't like it,
walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry,
or
acupuncture, or whatever, there is an insurance company somewhere
which
will provide the desired coverage. Not so with government funded
health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the
overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all.  If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested.  Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
That aside, Medicaid is there to take care of these situations - why
doesn't it?
allan
Because states see much of it as an unfunded requirement that they don't want to
assume.
You have to make yourself a pauper to qualify for Medicaid,
That is why they call it welfare, Rita. Rich people with two cars,
summer homes on Long Island and Macmansions don't qualify.
Post by Rita
a step
many middle class people who are faced with enormous medical costs are
reluctant to take --
How do you know this?
Post by Rita
it can mean giving up a job and any savings
you have managed.  
This is completely false, Rita. If you have wages 300% or higher than
the poverty line AND have savings, you should be paying for health
insurance.
Post by Rita
In order for it to serve the purpose Alan suggests
the income and asset limits to receive it  would have to be
drastically increased.
And this is a solution to the problem - change the unemployment
insurance and welfare systems to accomodate the reality of job loss,
not the medical system.
Post by Rita
And it is not only those who lose their jobs because they get sick
who are faced with medical bankruptcies.  
Job loss and debt are the two drivers of bankruptcy. Medical debt is
a small fraction of total debt in bankruptcy. Read Dramove and
Milensone, not just Himmelstein.

allan
Evelyn
2009-09-15 13:23:34 UTC
Permalink
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the
overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.

That aside, Medicaid is there to take care of these situations - why
doesn't it?

allan



*****************

Because you need to be flat broke to get medicaid. No house, no emergency
cash, no nothing.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 19:36:37 UTC
Permalink
Evelyn wrote - regarding Medicaid's requirements:"No house - no
emergency cash - no nothing."
That is not correct.
One CAN have a house - - one can have , I believe, something like
$2,000.-
but then, every State has different regulations, but that is what they
are in MA.
Olly
Rita
2009-09-15 13:58:53 UTC
Permalink
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all.  If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested.  Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.

I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.

This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
.
High Miles
2009-09-15 14:26:56 UTC
Permalink
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
Rita
2009-09-15 14:41:21 UTC
Permalink
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
Evelyn
2009-09-15 14:44:11 UTC
Permalink
Post by Rita
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that
the
best treatments can be selected. That is far more than (but
may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and
agree to the
private contract before it is signed, or if he/she doesn't like
it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or
optometry, or
acupuncture, or whatever, there is an insurance company
somewhere which
will provide the desired coverage. Not so with government
funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the
overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
They just want to be assured that you didn't transfer your assets to your
kids to avoid using them for your own care. Yes, it sucks. They want not
only YOU to be bankrupt, but for your kids to not inherit either As long as
you have a buck it is theirs.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Rita
2009-09-15 15:19:35 UTC
Permalink
Post by Evelyn
Post by Rita
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies,
comparative
effectiveness is the study of alternative treatments so that
the
best treatments can be selected. That is far more than (but
may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for,
not
"that the best treatments can be selected". This is precisely
how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats.
Will it
happen immediately? Obviously not. Will it, in time, result
in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or
without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and
agree to the
private contract before it is signed, or if he/she doesn't like
it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or
optometry, or
acupuncture, or whatever, there is an insurance company
somewhere which
will provide the desired coverage. Not so with government
funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the
overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
They just want to be assured that you didn't transfer your assets to your
kids to avoid using them for your own care. Yes, it sucks. They want not
only YOU to be bankrupt, but for your kids to not inherit either As long as
you have a buck it is theirs.
Actually, I don't have a problem with the kids not inheriting part of
it.
High Miles
2009-09-15 15:32:19 UTC
Permalink
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
Ah but I - can not bear the thought of three generations of work and
care for the places going to support my care in some warehouse.
I have a revolver next to my bed for more than home invaders.
The kids have all been warned not to let me get too goofy to do
what needs to be done.
Or - they can be foolish enough to try and care for me themselves.
Medicaid is NOT a good way to go.
Evelyn
2009-09-15 15:41:07 UTC
Permalink
Post by High Miles
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
Ah but I - can not bear the thought of three generations of work and
care for the places going to support my care in some warehouse.
I have a revolver next to my bed for more than home invaders.
The kids have all been warned not to let me get too goofy to do
what needs to be done.
Or - they can be foolish enough to try and care for me themselves.
Medicaid is NOT a good way to go.
Often it is the only way.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 20:25:41 UTC
Permalink
Dorothy wrote:"Medicaid is not a good way to go- - she also spoke of a
revolver next to her...."
I can only repeat my tired refrain:"Chacun a sons mauvais gout." Yes,
mauvais.
Olly
Rumpelstiltskin
2009-09-15 16:41:59 UTC
Permalink
On Tue, 15 Sep 2009 10:32:19 -0500, High Miles
Post by High Miles
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
Ah but I - can not bear the thought of three generations of work and
care for the places going to support my care in some warehouse.
I have a revolver next to my bed for more than home invaders.
The kids have all been warned not to let me get too goofy to do
what needs to be done.
Or - they can be foolish enough to try and care for me themselves.
Medicaid is NOT a good way to go.
I ran into an old neighbor at the coffee shop yesterday.
She was studying for her nursing exams. I mentioned my
mom's last months with liver cancer, and then mentioned
that I'd heard that one could commit suicide easily by
taking lots of tylenol and alcohol. If I'd been thinking
better, I'd have realized that would be an uncomfortable
thing to bring up to somebody who was studying to be a
nurse, whose commitment is, not shamefully, to keep the
blood flowing through the veins no matter what. She
said it would work but it was ugly, and I said that if I was
unconscious that would be OK. She dropped the
topic at that point, and I had realized by then that it
wasn't something I should be pressing her about.
Evelyn
2009-09-15 17:08:46 UTC
Permalink
Post by Rumpelstiltskin
On Tue, 15 Sep 2009 10:32:19 -0500, High Miles
Post by High Miles
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
Ah but I - can not bear the thought of three generations of work and
care for the places going to support my care in some warehouse.
I have a revolver next to my bed for more than home invaders.
The kids have all been warned not to let me get too goofy to do
what needs to be done.
Or - they can be foolish enough to try and care for me themselves.
Medicaid is NOT a good way to go.
I ran into an old neighbor at the coffee shop yesterday.
She was studying for her nursing exams. I mentioned my
mom's last months with liver cancer, and then mentioned
that I'd heard that one could commit suicide easily by
taking lots of tylenol and alcohol. If I'd been thinking
better, I'd have realized that would be an uncomfortable
thing to bring up to somebody who was studying to be a
nurse, whose commitment is, not shamefully, to keep the
blood flowing through the veins no matter what. She
said it would work but it was ugly, and I said that if I was
unconscious that would be OK. She dropped the
topic at that point, and I had realized by then that it
wasn't something I should be pressing her about.
A friend of mine from another newsgroup always talked about a helium
rebreather device for suicide. There supposedly are instructions on the
internet somewhere and it is supposed to be a painless way to go and cheap
and the parts are available.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
High Miles
2009-09-15 17:14:43 UTC
Permalink
Post by Rumpelstiltskin
On Tue, 15 Sep 2009 10:32:19 -0500, High Miles
Post by High Miles
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
Ah but I - can not bear the thought of three generations of work and
care for the places going to support my care in some warehouse.
I have a revolver next to my bed for more than home invaders.
The kids have all been warned not to let me get too goofy to do
what needs to be done.
Or - they can be foolish enough to try and care for me themselves.
Medicaid is NOT a good way to go.
I ran into an old neighbor at the coffee shop yesterday.
She was studying for her nursing exams. I mentioned my
mom's last months with liver cancer, and then mentioned
that I'd heard that one could commit suicide easily by
taking lots of tylenol and alcohol. If I'd been thinking
better, I'd have realized that would be an uncomfortable
thing to bring up to somebody who was studying to be a
nurse, whose commitment is, not shamefully, to keep the
blood flowing through the veins no matter what. She
said it would work but it was ugly, and I said that if I was
unconscious that would be OK. She dropped the
topic at that point, and I had realized by then that it
wasn't something I should be pressing her about.
I believe there are still organizations, that can be found on line,
which offer all manner of humane methods for ...........exit.
Evelyn
2009-09-15 15:40:36 UTC
Permalink
Post by Rita
Post by Evelyn
Post by Rita
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies,
comparative
effectiveness is the study of alternative treatments so
that
the
best treatments can be selected. That is far more than
(but
may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies
will
determine which procedure government insurance will PAY for,
not
"that the best treatments can be selected". This is precisely
how
NICE functions in the UK. Yet another decision taken away
from
doctor/patient to be made by the centralized bureaucrats.
Will it
happen immediately? Obviously not. Will it, in time, result
in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or
without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and
agree to the
private contract before it is signed, or if he/she doesn't like
it, walk
away; not so with government funded health care, which is
what
the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or
optometry, or
acupuncture, or whatever, there is an insurance company
somewhere which
will provide the desired coverage. Not so with government
funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an
insurance
company who will provide desired coverage. thus, the
rationing
in
private insurance is based in large part on ability to pay.
the
overall
rationing must be the same (the economy supports the same
amount
of
health care spending in the two cases), but those without
means
will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance
plan
that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well
to
do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
They just want to be assured that you didn't transfer your assets to your
kids to avoid using them for your own care. Yes, it sucks. They want not
only YOU to be bankrupt, but for your kids to not inherit either As long as
you have a buck it is theirs.
Actually, I don't have a problem with the kids not inheriting part of
it.
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Rita
2009-09-15 16:00:15 UTC
Permalink
Post by Evelyn
Post by Rita
Post by Evelyn
Post by Rita
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies,
comparative
effectiveness is the study of alternative treatments so
that
the
best treatments can be selected. That is far more than
(but
may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies
will
determine which procedure government insurance will PAY
for,
not
"that the best treatments can be selected". This is
precisely
how
NICE functions in the UK. Yet another decision taken away
from
doctor/patient to be made by the centralized bureaucrats.
Will it
happen immediately? Obviously not. Will it, in time, result
in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or
without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and
agree to the
private contract before it is signed, or if he/she doesn't like
it, walk
away; not so with government funded health care, which is
what
the
discussion was about. And if a consumer deems it important to
be
covered, for say, sex change operations, or dentistry, or
optometry, or
acupuncture, or whatever, there is an insurance company
somewhere which
will provide the desired coverage. Not so with government
funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an
insurance
company who will provide desired coverage. thus, the
rationing
in
private insurance is based in large part on ability to pay.
the
overall
rationing must be the same (the economy supports the same
amount
of
health care spending in the two cases), but those without
means
will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance
plan
that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well
to
do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
They just want to be assured that you didn't transfer your assets to your
kids to avoid using them for your own care. Yes, it sucks. They want not
only YOU to be bankrupt, but for your kids to not inherit either As long as
you have a buck it is theirs.
Actually, I don't have a problem with the kids not inheriting part of
it.
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
You might like to do that, but not at taxpayers' expense I would
think. Few in nursing homes have minor children in need of support.
You are saying the right to an inheritance is absolute even if
that means the taxpayers foot the nursing home charges? That
assets should be preserved solely so some people can inherit them?
Rumpelstiltskin
2009-09-15 16:42:02 UTC
Permalink
<snip>
Post by Rita
Post by Evelyn
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
You might like to do that, but not at taxpayers' expense I would
think. Few in nursing homes have minor children in need of support.
You are saying the right to an inheritance is absolute even if
that means the taxpayers foot the nursing home charges? That
assets should be preserved solely so some people can inherit them?
I agree that you have a point, and that's why I brought up
the suicide option. If health care in America is not going to
let us die naturally without bankrupting us first, then we do
have, as governor Babbit suggested long ago, a duty to die
if we want to leave anything behind to maybe make things
a little easier for the next generation, rather than further
stuffing the bellies of strangers who are already overfed.

Suicide was quite normal in Roman times. There were
places you could go to get it done as pleasantly as possible.
High Miles
2009-09-15 17:04:21 UTC
Permalink
Post by Rumpelstiltskin
<snip>
Post by Rita
Post by Evelyn
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
You might like to do that, but not at taxpayers' expense I would
think. Few in nursing homes have minor children in need of support.
You are saying the right to an inheritance is absolute even if
that means the taxpayers foot the nursing home charges? That
assets should be preserved solely so some people can inherit them?
I agree that you have a point, and that's why I brought up
the suicide option. If health care in America is not going to
let us die naturally without bankrupting us first, then we do
have, as governor Babbit suggested long ago, a duty to die
if we want to leave anything behind to maybe make things
a little easier for the next generation, rather than further
stuffing the bellies of strangers who are already overfed.
Suicide was quite normal in Roman times. There were
places you could go to get it done as pleasantly as possible.
Too bad we don't have such a civilized society in play today.
Our system just doesn't make sense.
I suppose because it is supported by those clowns who believe
that life is some sort of sacred gifts from some gods.
Evelyn
2009-09-15 17:05:50 UTC
Permalink
Post by Rita
Post by Evelyn
Post by Rita
Post by Evelyn
Post by Rita
On Tue, 15 Sep 2009 09:26:56 -0500, High Miles
Post by High Miles
Post by Rita
On Tue, 15 Sep 2009 05:41:16 -0700 (PDT), Allan
Post by Allan
Post by Rita
Post by El Castor
Post by Rita
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies,
comparative
effectiveness is the study of alternative treatments so
that
the
best treatments can be selected. That is far more than
(but
may
include) discontinuing treatments that are not
effective.
Close, but no cigar. The comparative effectiveness
studies
will
determine which procedure government insurance will PAY
for,
not
"that the best treatments can be selected". This is
precisely
how
NICE functions in the UK. Yet another decision taken away
from
doctor/patient to be made by the centralized bureaucrats.
Will it
happen immediately? Obviously not. Will it, in time,
result
in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or
without
government insurance. the decision will be made by either
a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and
agree to the
private contract before it is signed, or if he/she doesn't
like
it, walk
away; not so with government funded health care, which is
what
the
discussion was about. And if a consumer deems it important to
be
covered, for say, sex change operations, or dentistry, or
optometry, or
acupuncture, or whatever, there is an insurance company
somewhere which
will provide the desired coverage. Not so with government
funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an
insurance
company who will provide desired coverage. thus, the
rationing
in
private insurance is based in large part on ability to pay.
the
overall
rationing must be the same (the economy supports the same
amount
of
health care spending in the two cases), but those without
means
will
face greater rationing.
Consumers with greater financial resources can afford a
larger
than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance
plan
that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who
can't
afford some level of basic health care must be provided with it.
if as
a result of that subsidy, there isn't enough money for the well
to
do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Your concern for well to do persons is far, far greater than any
concern I have EVER heard you express for those who are shut out of
having any health insurance at all. If you ever have expressed such
concern I must have missed it and you can direct me to it.
Now, now Rita. Just trying to figure out if you and Josh are promoting
"universality", Canadian style.
Since you brought it up, let me express concern for the 15
million
who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
People lose their health insurance daily for a variety of reasons -
some can't buy it even though not poor for medical reasons, many
who are not exactly in the poor house undergo medical bankruptcies
as the AMA has attested. Doctors say they prefer a mix of public
and private plans.
But you know all that.
People who lose their jobs because they get sick have these
bankruptcies Rita - it is job loss, not health.
You may have a job but the medical bills are of such magntitude
that you can't pay them out of that income. Do you have any
stats to show that those who take medical bankruptcies are
jobless?
Post by Allan
That aside, Medicaid is there to take care of these situations - why
doesn't it?
Medicaid has both income and asset limits. And they are very, very
low. I'm sure you know that. You could be employed, have an illness
that requires very expensive ongoing treatment, and not qualify for
Medicaid.
I did government benefit counseling for 10 years and talked to
many who had to make a tough choice -- make themselves a pauper in
order to receive needed medical care.
This can happen to many hard working, middle class folks. You can
lose anything you have managed to save or even quit your job in order
to receive Medicaid.
Post by Allan
allan
And you can't even give it to your heirs to protect their interests, unless
you beat the "look back" period in your state.
You'd almost have to be psychic, or very old to predict health conditions
far enough in advance to achieve that.
I think you are talking about qualifying for Medicaid for nursing
home care. The rules for that are different than for "regular"
Medicaid. The "look back" period applies to Medicaid for nursing
home care.
They just want to be assured that you didn't transfer your assets to your
kids to avoid using them for your own care. Yes, it sucks. They want not
only YOU to be bankrupt, but for your kids to not inherit either As long as
you have a buck it is theirs.
Actually, I don't have a problem with the kids not inheriting part of
it.
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
You might like to do that, but not at taxpayers' expense I would
think. Few in nursing homes have minor children in need of support.
You are saying the right to an inheritance is absolute even if
that means the taxpayers foot the nursing home charges? That
assets should be preserved solely so some people can inherit them?
Not a lot, but some. I think that NOBODY should lose their home due to
medical bills.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 20:28:56 UTC
Permalink
Rita wrote:"Assets should be preserved solely so that people can inherit
them?"
My personal reply would be:"YES!!!
I was not born to save society - but i do want to help my kids, if it is
legal, and if I can.
Olly
Rumpelstiltskin
2009-09-15 16:42:00 UTC
Permalink
<snip>
Post by Evelyn
Post by Rita
Actually, I don't have a problem with the kids not inheriting part of
it.
I do to some degree. We all would like to leave something for the kids.
It isn't a part, Rita. It's nothing other than personal effects.
With medical costs the way they are, suicide is really the only
way to go. The question is whether I, like yourself and others,
will be compos menti enough and gutsy enough to do the deed
when the time comes that it should be done.

I don't even have kids of my own, but I'd like to leave
something to my niece and nephew, not that I have any
confidence they'll take care of the money wisely. My sister is
eight years younger than me and a woman, so she'll likely
outlive me by quite a bit and will get the money first. She has
a much cooler head on her shoulders. Maybe by the time
she dies, her kids will have gotten some sense, though of
course there's no sign of that so far, but there rarely is until
people hit age 30 at least, maybe 35 or 40.
Olly Mensch
2009-09-17 20:19:40 UTC
Permalink
Evelyn wrote - regarding the "look-back" period which applies to Nursing
Home applications: (among other things)
"They just want to be assured that you did not transfer your assets to
your kids, to avoid using them for your own care. They want not only YOU
to be bankrupt, but for your kids to not inherit either. As long as you
have a buck, it is theirs."
= = Well, that is such gross and flawed thinking -coming from a liberal
- it is astounding. I guess when it comes tgo one's own pocketbooki -
then- in many cases, they are no longer liberal!!! Medicaid is handled
differently by different States. It is established to help the poor,
who cannot afford, and have no means for their own care. They do not
WANT you to be bankrupt (as Evelyn wrote) but, since Medicaid is a free
"hand-out", why on earth should it ever go to anyone who has some means
to help him/herself. Soooo - that justifies their demand for the
"look-back" period. Unlike what the "furious' Evelyn wrote- and she is
wrong - they do not want you to be broke - but they also were not
established by the Government to be helping those who can help
themselves.
Many elders transfer some of their assets to their children, in order to
be eligible, some day, for Medicaid. One could well argue about that,
but it is legal - and accepted, and recognized by Medicaid, and that is
why they established the five-year "look-back' period,during which time
one can no longer transfer assets, and if one does, that will be added
to the time they will NOT be paying you for NSG. Home care.
I all sounds vey fair to me - although it certainly is NOT to my
personal advantage, but that does not mean it is not fair.
Olly
Rita
2009-09-17 20:50:06 UTC
Permalink
Post by Olly Mensch
Evelyn wrote - regarding the "look-back" period which applies to Nursing
Home applications: (among other things)
"They just want to be assured that you did not transfer your assets to
your kids, to avoid using them for your own care. They want not only YOU
to be bankrupt, but for your kids to not inherit either. As long as you
have a buck, it is theirs."
= = Well, that is such gross and flawed thinking -coming from a liberal
- it is astounding. I guess when it comes tgo one's own pocketbooki -
then- in many cases, they are no longer liberal!!! Medicaid is handled
differently by different States. It is established to help the poor,
who cannot afford, and have no means for their own care. They do not
WANT you to be bankrupt (as Evelyn wrote) but, since Medicaid is a free
"hand-out", why on earth should it ever go to anyone who has some means
to help him/herself. Soooo - that justifies their demand for the
"look-back" period. Unlike what the "furious' Evelyn wrote- and she is
wrong - they do not want you to be broke - but they also were not
established by the Government to be helping those who can help
themselves.
Many elders transfer some of their assets to their children, in order to
be eligible, some day, for Medicaid. One could well argue about that,
but it is legal - and accepted, and recognized by Medicaid, and that is
why they established the five-year "look-back' period,during which time
one can no longer transfer assets, and if one does, that will be added
to the time they will NOT be paying you for NSG. Home care.
I all sounds vey fair to me - although it certainly is NOT to my
personal advantage, but that does not mean it is not fair.
Olly
One may argue reasonably a right to health care -- those who go
to nursing homes are helpless individuals who need full-time care
and to not provide it would be more than cruel.

But I don't believe there is a comparable right to inherit from
one's parents when that money could first be used to provide
the care parents need when elderly and infirm. And instead, preserve
the estate to go to those children and let the taxpayers foot the
bill. As I pointed out these adult children are not minors, their
parents are no longer responsible for seeing to their welfare.

This may be a disappointment for adult children who were
hoping to inherit. But it is a very just law insofar as the overall
public good is concerned and they should get over it.

So I agree with you, Olly.
Olly Mensch
2009-09-17 19:53:59 UTC
Permalink
Yes, one CAN give what one chooses to one's heirs, provided that the
application for Medicaid is beyond the so-called "look-back' period.
Thousands of Seniors have turned over their homes, and much of their
assets - over the years to their heirs - and then, after a
certain"punishment" (look-back) period, were, indeed, eligible for
Medicaid, if they had reduced heir assets enough.
That kind of manipulation is highly debatable, or ethical??? - but very
popular, and not illegal.
Talk about protective insurance: I took out Nursing Home Insurance
years and years ago. It was frightfully expensive - and still is. As
it turns out, though, if I were to want to; or need to enter a Nursing
home, it would in no way cover the day to day expenses there - since it
all has gone up so drastically. So - in retrospect, all those horrid
payments for that ins. were wasted - practically - yet, I am still
paying them, since they at least pay perhaps one/tenth of the dailyt
fees for a room in a Nsg. Home. I should have listened to my late
husband, who never wanted to buy that type of insurance, but, right
after he died, I did buy it, thinking it is a good protection. My
mistake was that I did NOT also buy inflation insurance, which they
offered. The eason I did not, is bec. the fees were so ridiculously
expensive anyway that, with inflation insurance added to it, it would
have been financially impossible for me. Yet - that was a mistake I
made.
Olly
Josh Rosenbluth
2009-09-15 13:25:06 UTC
Permalink
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?

Josh Rosenbluth
Islander
2009-09-15 14:28:04 UTC
Permalink
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
Josh Rosenbluth
I'm not sure that your statement is true, Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.

The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.

http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
Rumpelstiltskin
2009-09-15 16:41:59 UTC
Permalink
Post by Islander
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
Josh Rosenbluth
I'm not sure that your statement is true, Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
It is indeed disheartening. I've almost completely given
up on any chance of real health care reform now. We're
just going to continue to have a health care system that's
both the most expensive and one of the least effective
in the civilized world. The health care insurance industry
with the help of its tea-party suckers will have won the day.
Evelyn
2009-09-15 17:09:54 UTC
Permalink
Post by Rumpelstiltskin
Post by Islander
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
Josh Rosenbluth
I'm not sure that your statement is true, Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
It is indeed disheartening. I've almost completely given
up on any chance of real health care reform now. We're
just going to continue to have a health care system that's
both the most expensive and one of the least effective
in the civilized world. The health care insurance industry
with the help of its tea-party suckers will have won the day.
If they just get rid of the lifetime caps, and the pre existing conditions
it will be an improvement, but I still am hoping for single payer....
Medicare for all would be good.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 20:35:55 UTC
Permalink
Poor, benighted Rumple wrote of our health care industry as being the
"least effective in the civilized world"
I guess Rumple not only changed his web name, but also lost his marbles
- since our healthcare system is the best in the world. Always has
been. Some years ago, the King of Jordan flew here for an operation - -
and so do ever so many people who can choose where to have their
treatments done.
Olly
Josh Rosenbluth
2009-09-15 18:51:37 UTC
Permalink
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million.  My guess is your premimum for beyond the basic plan will go
up.  Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh.  It assumes that there
will be no improvement in efficiency by covering everyone.  The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient.  If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.

Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.

Josh Rosenbluth
Islander
2009-09-15 19:46:31 UTC
Permalink
Post by Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.
Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.
Josh Rosenbluth
I realize that the Republicans have been propagating the belief that
most people are satisfied with what they have. I'm not so sure. I'd
like to look closely at how that claim can be justified. Does it, for
example, include Medicare and VA recipients? Does it include union
workers who have fought hard to get their benefits?

I agree that people fear the unknown and that is significantly different
from being satisfied with what you have.
Islander
2009-09-17 16:27:47 UTC
Permalink
Post by Islander
Post by Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.
Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.
Josh Rosenbluth
I realize that the Republicans have been propagating the belief that
most people are satisfied with what they have. I'm not so sure. I'd
like to look closely at how that claim can be justified. Does it, for
example, include Medicare and VA recipients? Does it include union
workers who have fought hard to get their benefits?
I agree that people fear the unknown and that is significantly different
from being satisfied with what you have.
Following up on this widely believed story, I found the following:

There are numerous citations claiming to support this claim that go back
to a paper written by June and Paul O'Neill for the National Bureau of
Economic Research entitled "Health Status, Health Care and Inequality:
Canada vs. the U.S." The paper claims that 51.3% of Americans are very
satisfied with their health care services compared to 41.5% of Canadians.

I have several observations about this claim, its source, and how it is
being used:

1. 51.3% is hardly "most people."

2. The claim is made in the context of a comparison with Canada and is
therefore biased with American beliefs about Canadian health care.

3. It is not a claim about insurance, but about overall health care
services.

4. The authors evidently did not exclude Americans who are covered under
Medicare, Medicaid, VA, or benefits acquired by unions.

5. The National Bureau of Economic Research sounds like an important
federal agency. It is not. It is yet another private conservative
think tank that produces volumes of reports supporting conservative
causes.

6. The CEO of NBER is Martin S. Feldstein, who served as director of
Hospital Corporation of America and is currently director of Eli Lilly.

7. Once again we have an example of how the Republican Slime Machine
distorts information to make claims that are, in fact, blatant lies.

Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
Rita
2009-09-17 16:39:09 UTC
Permalink
Post by Islander
Post by Islander
Post by Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.
Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.
Josh Rosenbluth
I realize that the Republicans have been propagating the belief that
most people are satisfied with what they have. I'm not so sure. I'd
like to look closely at how that claim can be justified. Does it, for
example, include Medicare and VA recipients? Does it include union
workers who have fought hard to get their benefits?
I agree that people fear the unknown and that is significantly different
from being satisfied with what you have.
There are numerous citations claiming to support this claim that go back
to a paper written by June and Paul O'Neill for the National Bureau of
Canada vs. the U.S." The paper claims that 51.3% of Americans are very
satisfied with their health care services compared to 41.5% of Canadians.
I have several observations about this claim, its source, and how it is
1. 51.3% is hardly "most people."
2. The claim is made in the context of a comparison with Canada and is
therefore biased with American beliefs about Canadian health care.
3. It is not a claim about insurance, but about overall health care
services.
4. The authors evidently did not exclude Americans who are covered under
Medicare, Medicaid, VA, or benefits acquired by unions.
5. The National Bureau of Economic Research sounds like an important
federal agency. It is not. It is yet another private conservative
think tank that produces volumes of reports supporting conservative
causes.
This is why I always check out the provenance of names of individuals
and organizations cited in support of or against some measure.

It is easy enough to do via Google. I have a Google search bar always
visible at the bottom of any computer page.
Post by Islander
6. The CEO of NBER is Martin S. Feldstein, who served as director of
Hospital Corporation of America and is currently director of Eli Lilly.
7. Once again we have an example of how the Republican Slime Machine
distorts information to make claims that are, in fact, blatant lies.
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
Islander
2009-09-17 16:51:43 UTC
Permalink
Post by Rita
Post by Islander
Post by Islander
Post by Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.
Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.
Josh Rosenbluth
I realize that the Republicans have been propagating the belief that
most people are satisfied with what they have. I'm not so sure. I'd
like to look closely at how that claim can be justified. Does it, for
example, include Medicare and VA recipients? Does it include union
workers who have fought hard to get their benefits?
I agree that people fear the unknown and that is significantly different
from being satisfied with what you have.
There are numerous citations claiming to support this claim that go back
to a paper written by June and Paul O'Neill for the National Bureau of
Canada vs. the U.S." The paper claims that 51.3% of Americans are very
satisfied with their health care services compared to 41.5% of Canadians.
I have several observations about this claim, its source, and how it is
1. 51.3% is hardly "most people."
2. The claim is made in the context of a comparison with Canada and is
therefore biased with American beliefs about Canadian health care.
3. It is not a claim about insurance, but about overall health care
services.
4. The authors evidently did not exclude Americans who are covered under
Medicare, Medicaid, VA, or benefits acquired by unions.
5. The National Bureau of Economic Research sounds like an important
federal agency. It is not. It is yet another private conservative
think tank that produces volumes of reports supporting conservative
causes.
This is why I always check out the provenance of names of individuals
and organizations cited in support of or against some measure.
It is easy enough to do via Google. I have a Google search bar always
visible at the bottom of any computer page.
Post by Islander
6. The CEO of NBER is Martin S. Feldstein, who served as director of
Hospital Corporation of America and is currently director of Eli Lilly.
7. Once again we have an example of how the Republican Slime Machine
distorts information to make claims that are, in fact, blatant lies.
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
As you say, easy enough to do. There are now quite a few resources out
there to help find information about organizations and individuals. For
this little piece, I used sourcewatch.org and a research service of
BusinessWeek.
Rita
2009-09-17 17:13:00 UTC
Permalink
Post by Islander
Post by Rita
Post by Islander
Post by Islander
Post by Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
Since you brought it up, let me express concern for the 15 million who
don't qualify for Medicaid, but need help in affording Obamacare
insurance. Let's take care of them, but can the rest of us be left
alone?
Macromeconomics demand that someone has to pay for covering the 15
million. My guess is your premimum for beyond the basic plan will go
up. Not sure if that qualifies as being left alone?
I'm not sure that your statement is true,Josh. It assumes that there
will be no improvement in efficiency by covering everyone. The
experience of other nations seems to me to indicate that we should be
paying less for better care if we were to go to a single payer system.
Unfortunately, we won't get that, so it is likely that whatever we get
will be less efficient. If we lose the public option too, I fear that
we will all be paying more for less.
The article cited below is long, but does a good job of arguing that we
have left the best parts of health care reform on the cutting room floor.
http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1
The article claims it is government as insurer that unlocks the cost
savings. Jeff's idea of being left alone is to have an option to
continue his current coverage. That option is not going to be
available if the cost savings are to be realized.
Maybe the cost savings would result in a basic plan that is at least
as good as what Jeff now gets, convincing him he doesn't need his
plan. But, it's a tough sell when most people are happy with what
they have, and fear something new, something that may or may not
produce what it promises.
Josh Rosenbluth
I realize that the Republicans have been propagating the belief that
most people are satisfied with what they have. I'm not so sure. I'd
like to look closely at how that claim can be justified. Does it, for
example, include Medicare and VA recipients? Does it include union
workers who have fought hard to get their benefits?
I agree that people fear the unknown and that is significantly different
from being satisfied with what you have.
There are numerous citations claiming to support this claim that go back
to a paper written by June and Paul O'Neill for the National Bureau of
Canada vs. the U.S." The paper claims that 51.3% of Americans are very
satisfied with their health care services compared to 41.5% of Canadians.
I have several observations about this claim, its source, and how it is
1. 51.3% is hardly "most people."
2. The claim is made in the context of a comparison with Canada and is
therefore biased with American beliefs about Canadian health care.
3. It is not a claim about insurance, but about overall health care
services.
4. The authors evidently did not exclude Americans who are covered under
Medicare, Medicaid, VA, or benefits acquired by unions.
5. The National Bureau of Economic Research sounds like an important
federal agency. It is not. It is yet another private conservative
think tank that produces volumes of reports supporting conservative
causes.
This is why I always check out the provenance of names of individuals
and organizations cited in support of or against some measure.
It is easy enough to do via Google. I have a Google search bar always
visible at the bottom of any computer page.
Post by Islander
6. The CEO of NBER is Martin S. Feldstein, who served as director of
Hospital Corporation of America and is currently director of Eli Lilly.
7. Once again we have an example of how the Republican Slime Machine
distorts information to make claims that are, in fact, blatant lies.
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
As you say, easy enough to do. There are now quite a few resources out
there to help find information about organizations and individuals. For
this little piece, I used sourcewatch.org and a research service of
BusinessWeek.
I'll put Sourcewatch in my "Links".
Emily
2009-09-17 17:13:07 UTC
Permalink
Post by Islander
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
There must be some number of people who have never used their health
insurance for anything more than routine physicals, medications, maybe
a few x-rays, and they're no doubt happy. The insurance companies
aren't likely to drop you for a broken leg or having your tonsils
removed. It would be interesting to see a survey of people who have
had large medical bills, including the ones who went bankrupt.
Evelyn
2009-09-17 17:20:00 UTC
Permalink
Post by Emily
Post by Islander
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
There must be some number of people who have never used their health
insurance for anything more than routine physicals, medications, maybe
a few x-rays, and they're no doubt happy. The insurance companies
aren't likely to drop you for a broken leg or having your tonsils
removed. It would be interesting to see a survey of people who have
had large medical bills, including the ones who went bankrupt.
Heaven forbid you get cancer or need some extensive surgeries, or expensive
rare meds........That is when the cap kicks in, and you are left high and
dry even with good medical insurance coverage. So then you mortgage or
refinance your home, can't pay and end up homeless, in debt, and sick to
boot.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Olly Mensch
2009-09-17 20:48:22 UTC
Permalink
Without wanting to - yet again - argue with Evelyn- but her post
requires an answer, in that I have had - during my lfetime, all the
conditions, hospitalizations, surgeries,which she mentioned in her post
as being the end of insurance - so to speak - That is simply not true.
Never did we, my huband or I, have a problem; our insurances always
functioned as they were supposed to. Where does she get that mindset
-must be - yet again - her liberal bias .
Olly
Islander
2009-09-17 17:23:04 UTC
Permalink
Post by Emily
Post by Islander
Bottom line: "Most" Americans are *not* happy with their health
insurance. Some are, some simply haven't thought much about it since
they assume that having health insurance actually protects them. One
author describes this as similar to how one feels about a new car before
driving it out of the showroom.
There must be some number of people who have never used their health
insurance for anything more than routine physicals, medications, maybe
a few x-rays, and they're no doubt happy. The insurance companies
aren't likely to drop you for a broken leg or having your tonsils
removed. It would be interesting to see a survey of people who have
had large medical bills, including the ones who went bankrupt.
Indeed! This cuts to the very heart of whether the profit motive of
insurance companies is useful. I'm afraid that we are moving toward a
system of regulations rather than true competition that would result
from a public option. Regulations, by themselves, will only increase
cost to the consumer, IMV.
Olly Mensch
2009-09-17 20:42:52 UTC
Permalink
Emily - - I have had - in the past - large, large medical bills - for
surgery for cancer of the colon -for two heart attacks, and various
other,not as serious conditions.
NEVER - ever had a problem with any of my insuances.
Olly

Olly Mensch
2009-09-17 19:57:18 UTC
Permalink
Islander - I never thought the day would come that I could agree with
you! It has come! I hope that is not a life-altering experience for
you.....:-) You wrote:" If we lose the public option, we will all be
paying more for less.'
How right you are.
Olly
Josh Rosenbluth
2009-09-14 20:23:16 UTC
Permalink
On Sun, 13 Sep 2009 20:57:05 -0400,JoshRosenbluth
On Sun, 13 Sep 2009 11:52:18 -0400,JoshRosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected.  That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar.  de facto rationing will occur with or without
government insurance.  the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage.  thus, the rationing in
private insurance is based in large part on ability to pay.  the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure.  but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it.  if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan?
I said "sure" - that would be a "yes".
Islander
2009-09-15 01:54:55 UTC
Permalink
Post by El Castor
On Sun, 13 Sep 2009 20:57:05 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by El Castor
On Sun, 13 Sep 2009 11:52:18 -0400, Josh Rosenbluth
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
only a consumer of unlimited means can walk away or find an insurance
company who will provide desired coverage. thus, the rationing in
private insurance is based in large part on ability to pay. the overall
rationing must be the same (the economy supports the same amount of
health care spending in the two cases), but those without means will
face greater rationing.
Consumers with greater financial resources can afford a larger than
average house, a nicer car, and a better cut of meat. Should that
consumer also be allowed to pay more for a health insurance plan that
provides for more testing and diagnostic services?
sure. but first, unlike your other examples, the consumer who can't
afford some level of basic health care must be provided with it. if as
a result of that subsidy, there isn't enough money for the well to do to
any longer afford additional health care, then so be it.
Well, let's just assume that one of these "well to do" persons can
afford something better than the basic health care provided by the
government -- maybe annual PSA tests or mammograms if they are not
provided in the "basic" -- or perhaps a one week wait for an MRI,
rather than one month in the basic plan? Should that be allowed?
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the "basic"
plan or that one would have to wait for a month for an MRI. That has
not been my experience in our "basic" system, Medicare. Nor is it the
experience that many people have in other universal health care systems,
despite the few anecdotal stories cited by Jeff.

His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line. My
understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited
care. It appears that wealth has its privileges everywhere.
High Miles
2009-09-15 02:21:44 UTC
Permalink
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the "basic"
plan or that one would have to wait for a month for an MRI. That has
not been my experience in our "basic" system, Medicare. Nor is it the
experience that many people have in other universal health care systems,
despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line. My
understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited
care. It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.

Take some offense for me too while your at it.
Rumpelstiltskin
2009-09-15 02:52:32 UTC
Permalink
On Mon, 14 Sep 2009 21:21:44 -0500, High Miles
<snip>
Post by High Miles
Either these guys are lying, or trying to make a point the republican way.
? That's only one thing.
High Miles
2009-09-15 13:46:59 UTC
Permalink
Post by Rumpelstiltskin
On Mon, 14 Sep 2009 21:21:44 -0500, High Miles
<snip>
Post by High Miles
Either these guys are lying, or trying to make a point the republican way.
? That's only one thing.
Gee............................ya think ? ;-)
Evelyn
2009-09-15 10:39:25 UTC
Permalink
Post by High Miles
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the "basic"
plan or that one would have to wait for a month for an MRI. That has not
been my experience in our "basic" system, Medicare. Nor is it the
experience that many people have in other universal health care systems,
despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line. My
understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited care.
It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.
Take some offense for me too while your at it.
My one complaint with Medicare is that they only pay for a pap smear every 2
years, rather than annually. Not that big a deal......
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Islander
2009-09-15 14:17:23 UTC
Permalink
Post by Evelyn
Post by High Miles
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the
"basic" plan or that one would have to wait for a month for an MRI.
That has not been my experience in our "basic" system, Medicare. Nor
is it the experience that many people have in other universal health
care systems, despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line.
My understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS
is government run, one can purchase insurance to provide for
expedited care. It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.
Take some offense for me too while your at it.
My one complaint with Medicare is that they only pay for a pap smear
every 2 years, rather than annually. Not that big a deal......
Gasp! There, you see, you've been rationed!
Evelyn
2009-09-15 14:42:05 UTC
Permalink
Post by Islander
Post by Evelyn
Post by High Miles
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the
"basic" plan or that one would have to wait for a month for an MRI.
That has not been my experience in our "basic" system, Medicare. Nor
is it the experience that many people have in other universal health
care systems, despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line.
My understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited
care. It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.
Take some offense for me too while your at it.
My one complaint with Medicare is that they only pay for a pap smear
every 2 years, rather than annually. Not that big a deal......
Gasp! There, you see, you've been rationed!
Actually, yes. Most docs want one once a year.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Rumpelstiltskin
2009-09-15 14:37:39 UTC
Permalink
Post by Evelyn
Post by High Miles
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the "basic"
plan or that one would have to wait for a month for an MRI. That has not
been my experience in our "basic" system, Medicare. Nor is it the
experience that many people have in other universal health care systems,
despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line. My
understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited care.
It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.
Take some offense for me too while your at it.
My one complaint with Medicare is that they only pay for a pap smear every 2
years, rather than annually. Not that big a deal......
I just found out that I no longer get glasses from Kaiser. I
would have known that if I'd read the annual 50-page booklet
of benefits, but it would be hard to imagine anything much more
boring than reading that. I'd be so bored I wouldn't take it all
in anyway. Not getting glasses from Kaiser is actually no loss,
because Kaiser no longer has big frames. I could only get
glasses in the smaller frames that most people are using these
days. I did get reading glasses in those smaller frames last time,
because it was all there was, but I rarely use those glasses
because I find the smaller field of view annoying. I'll have to
check with the new provider to see if they have large frames,
and also to see if the $25 co-payment applies to the lenses
and frames together, for $25 total, or separately, for $50 total.
The 50 page booklet, in typical bureaucratic fashion, didn't
make that fundamental consideration clear. If it's $50, I'll
probably stick with what I have. If they don't have large
frames, I'll stick with what I have anyway, since my eyes
haven't changed much. In that case, I'll just get an eye test
for the sake of checking for glaucoma.
Evelyn
2009-09-15 14:45:16 UTC
Permalink
Post by Rumpelstiltskin
Post by Evelyn
Post by High Miles
Post by Islander
Personally, I take offense at the tactic of suggesting by implication
that annual PSA tests or mammograms would not be provided by the "basic"
plan or that one would have to wait for a month for an MRI. That has not
been my experience in our "basic" system, Medicare. Nor is it the
experience that many people have in other universal health care systems,
despite the few anecdotal stories cited by Jeff.
I've been cheerfully given any test requested.
Medicare pays without a whimper.
Either these guys are lying, or trying to make a point the republican way.
Post by Islander
His examples are not relevant to his basic question, specifically,
whether or not persons can purchase a place at the head of the line.
My
understanding is that this is possible in most of the nations that
provide universal health care systems. Even in the UK where the NHS is
government run, one can purchase insurance to provide for expedited care.
It appears that wealth has its privileges everywhere.
I got an MRI on the day my doc requested it, on Medicare, and I don't live
in a major metropolitan area.
Annual mammograms are absolutely paid for by Medicare, and more often
if some condition warrants.
Take some offense for me too while your at it.
My one complaint with Medicare is that they only pay for a pap smear every 2
years, rather than annually. Not that big a deal......
I just found out that I no longer get glasses from Kaiser. I
would have known that if I'd read the annual 50-page booklet
of benefits, but it would be hard to imagine anything much more
boring than reading that. I'd be so bored I wouldn't take it all
in anyway. Not getting glasses from Kaiser is actually no loss,
because Kaiser no longer has big frames. I could only get
glasses in the smaller frames that most people are using these
days. I did get reading glasses in those smaller frames last time,
because it was all there was, but I rarely use those glasses
because I find the smaller field of view annoying. I'll have to
check with the new provider to see if they have large frames,
and also to see if the $25 co-payment applies to the lenses
and frames together, for $25 total, or separately, for $50 total.
The 50 page booklet, in typical bureaucratic fashion, didn't
make that fundamental consideration clear. If it's $50, I'll
probably stick with what I have. If they don't have large
frames, I'll stick with what I have anyway, since my eyes
haven't changed much. In that case, I'll just get an eye test
for the sake of checking for glaucoma.
I hate those small frames. Especially for sunglasses.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Rumpelstiltskin
2009-09-15 16:42:00 UTC
Permalink
<snip>
Post by Evelyn
Post by Rumpelstiltskin
I just found out that I no longer get glasses from Kaiser. I
would have known that if I'd read the annual 50-page booklet
of benefits, but it would be hard to imagine anything much more
boring than reading that. I'd be so bored I wouldn't take it all
in anyway. Not getting glasses from Kaiser is actually no loss,
because Kaiser no longer has big frames. I could only get
glasses in the smaller frames that most people are using these
days. I did get reading glasses in those smaller frames last time,
because it was all there was, but I rarely use those glasses
because I find the smaller field of view annoying. I'll have to
check with the new provider to see if they have large frames,
and also to see if the $25 co-payment applies to the lenses
and frames together, for $25 total, or separately, for $50 total.
The 50 page booklet, in typical bureaucratic fashion, didn't
make that fundamental consideration clear. If it's $50, I'll
probably stick with what I have. If they don't have large
frames, I'll stick with what I have anyway, since my eyes
haven't changed much. In that case, I'll just get an eye test
for the sake of checking for glaucoma.
I hate those small frames. Especially for sunglasses.
I'm glad to see it's not just me. I was wondering if I was
just being weird again, or if it really was the case that a lot of
people really don't like the small frames, and the reason the
insurance-supported optometry outfits don't offer them is to
save money, perhaps for bigger executive bonuses.
Islander
2009-09-13 17:36:29 UTC
Permalink
Post by Matthew Scott
Post by Josh Rosenbluth
Post by Matthew Scott
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the
best treatments can be selected. That is far more than (but may
include) discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not
"that the best treatments can be selected". This is precisely how
NICE functions in the UK. Yet another decision taken away from
doctor/patient to be made by the centralized bureaucrats. Will it
happen immediately? Obviously not. Will it, in time, result in de
facto rationing? Certainly.
close, but no cigar. de facto rationing will occur with or without
government insurance. the decision will be made by either a
government or private-insurance bureaucrat.
Correct to a point, but a consumer has a chance to read and agree to the
private contract before it is signed, or if he/she doesn't like it, walk
away; not so with government funded health care, which is what the
discussion was about. And if a consumer deems it important to be
covered, for say, sex change operations, or dentistry, or optometry, or
acupuncture, or whatever, there is an insurance company somewhere which
will provide the desired coverage. Not so with government funded health
care and comparative effectiveness studies.
It's fun to speculate about the 'unintended consequences' of ObamaCare.
Given all the regulation in the works (community rating, guaranteed
acceptance, prohibition of caps, etc) I wonder what the actuaries have
to say on the matter. It sounds to me as if the insurance companies are
going to be so tightly regulated that their autonomy will be
questionable, and they will become nothing more than executors of
government policy. It'll be interesting to see how many decide to stay
in the business, long term.
I seriously doubt that Medicare as currently configured (Parts A & B)
comply with ObamaCare's regulations. Wonder how they're gonna fix that
little glitch.
It may be "fun" for you to speculate, but this is literally deadly
serious for many people. On Meet-the-Press this morning, one of the
panelists observed that Congress is prone to regulate the last problem
and not anticipate the next problem. Regulation is needed, but it is
much more practical to have an alternative in place when the insurance
industry finds new "creative" ways to write insurance policies. One can
be sure that they will, just as now most people are at a serious
disadvantage to the legal and marketing staffs of insurance companies.

So, you may have fun speculating, but until you come up with specifics
about "glitches," we would probably be well advised to just ignore your
"fun."
Islander
2009-09-13 14:43:10 UTC
Permalink
Post by Matthew Scott
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from doctor/patient
to be made by the centralized bureaucrats. Will it happen immediately?
Obviously not. Will it, in time, result in de facto rationing? Certainly.
You are speaking from fear rather than logic or knowledge of what
Comparative Effectiveness is or what is in the legislation. Read
section 1401 of H.R. 3200.

Rationing is a separate issue. If you are concerned about rationing,
you might consider whether decisions about rationing are better made by
a bureaucrat in some insurance company whose primary interest is saving
money or by a bureaucrat in a government agency who might make decisions
based on factors other than money. The government is not the problem on
this, it is a better solution.

I agree that decisions on treatment should be made by the patient and
doctor, but that is not the case today nor is it likely to be the case
in the future unless we eliminate health insurance entirely.
Rita
2009-09-13 15:16:42 UTC
Permalink
Post by Islander
Post by Matthew Scott
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from doctor/patient
to be made by the centralized bureaucrats. Will it happen immediately?
Obviously not. Will it, in time, result in de facto rationing? Certainly.
You are speaking from fear rather than logic or knowledge of what
Comparative Effectiveness is or what is in the legislation. Read
section 1401 of H.R. 3200.
Rationing is a separate issue. If you are concerned about rationing,
you might consider whether decisions about rationing are better made by
a bureaucrat in some insurance company whose primary interest is saving
money or by a bureaucrat in a government agency who might make decisions
based on factors other than money. The government is not the problem on
this, it is a better solution.
I agree that decisions on treatment should be made by the patient and
doctor, but that is not the case today nor is it likely to be the case
in the future unless we eliminate health insurance entirely.
Why doesn't anyone seem to point at the inability to afford health
insurance or to be deemed insurable by the insurance companies
as rationing of health care? Those are the ultimate rationing
problems.
Islander
2009-09-13 17:26:49 UTC
Permalink
Post by Rita
Post by Islander
Post by Matthew Scott
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from doctor/patient
to be made by the centralized bureaucrats. Will it happen immediately?
Obviously not. Will it, in time, result in de facto rationing? Certainly.
You are speaking from fear rather than logic or knowledge of what
Comparative Effectiveness is or what is in the legislation. Read
section 1401 of H.R. 3200.
Rationing is a separate issue. If you are concerned about rationing,
you might consider whether decisions about rationing are better made by
a bureaucrat in some insurance company whose primary interest is saving
money or by a bureaucrat in a government agency who might make decisions
based on factors other than money. The government is not the problem on
this, it is a better solution.
I agree that decisions on treatment should be made by the patient and
doctor, but that is not the case today nor is it likely to be the case
in the future unless we eliminate health insurance entirely.
Why doesn't anyone seem to point at the inability to afford health
insurance or to be deemed insurable by the insurance companies
as rationing of health care? Those are the ultimate rationing
problems.
Not only that, but also those who think that they are protected with
insurance only to find that it is "rationed" out of their reach by the
insurance companies when they need it.
Matthew Scott
2009-09-13 17:36:09 UTC
Permalink
Post by Rita
Post by Islander
Post by Matthew Scott
Post by Matthew Scott
[snip]
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will
determine which procedure government insurance will PAY for, not "that
the best treatments can be selected". This is precisely how NICE
functions in the UK. Yet another decision taken away from doctor/patient
to be made by the centralized bureaucrats. Will it happen immediately?
Obviously not. Will it, in time, result in de facto rationing? Certainly.
You are speaking from fear rather than logic or knowledge of what
Comparative Effectiveness is or what is in the legislation. Read
section 1401 of H.R. 3200.
Rationing is a separate issue. If you are concerned about rationing,
you might consider whether decisions about rationing are better made by
a bureaucrat in some insurance company whose primary interest is saving
money or by a bureaucrat in a government agency who might make decisions
based on factors other than money. The government is not the problem on
this, it is a better solution.
I agree that decisions on treatment should be made by the patient and
doctor, but that is not the case today nor is it likely to be the case
in the future unless we eliminate health insurance entirely.
Why doesn't anyone seem to point at the inability to afford health
insurance or to be deemed insurable by the insurance companies
as rationing of health care? Those are the ultimate rationing
problems.
No problem. But using a sledgehammer to kill a fly is questionable. I find it ridiculous that conservatives are accused of fighting to keep the status quo; the truth is that there are affordable solutions to the problem of 'access' to health service. Yesterday Eleanor Clift wrote an article pointing out that a major weakness in the "plan" for ObamaCare was that it was woefully short on imposition of the taxes which are necessary to support it. Obama has backed himself into a corner; he has "pledged" not to raise taxes on the middle class and he has "pledged" not to sign any health bill that impacts the national debt. So what does he do now?

Please remember that in the absence of anything but high falutin' campaign style rhetoric, Obama has proposed absolutely no detail of how the FedGov can accomplish his dream without plunging the country into ever deeper and deeper debt. That's the problem.
Jean Smith
2009-09-13 21:05:02 UTC
Permalink
Post by Matthew Scott
[snip]
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
Close, but no cigar. The comparative effectiveness studies will determine
which procedure government insurance will PAY for, not "that the best
treatments can be selected". This is precisely how NICE functions in the UK.
Yet another decision taken away from doctor/patient to be made by the
centralized bureaucrats. Will it happen immediately? Obviously not. Will it,
in time, result in de facto rationing? Certainly.
Science is not bureaucracy. Better informed physician will make better decisions.
--
C-SPAN http://www.c-spanarchives.org/#todaysEventsHeading
Check http://politifact.com http://healthcarefactcheck.com/
http://www.healthactionnow.org/?s_src=20090622_US_E_HAN_LaunchAT
Allan
2009-09-15 12:37:41 UTC
Permalink
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.

One of the examples cited in Gary's 10 is about technology - CAT and
MRI. MRI's are much better (more effective) in detecting small tumors
than traditional x-rays. CAT scanners are much better in evaluating
soft tissue injuries (sports injuries as an example) than x-rays. But
the argument is made that it is "wasteful" - and as such Comparative
Effectiveness data would suggest to use them and cost-effectiveness
likely would tell you not. I have plenty of other examples if you
like.
Post by Islander
Frankly, I'm surprised that the insurance industry is not supporting
comparative effectiveness.  Perhaps they have simply lost control of
their mobs.
The insurance industry - more specifically the medical managed care
industry - does use comparative effectiveness - moreover, they use
cost-effectiveness - you need to read the AMCP guidelines on dossier
submissions for pharmaceuticals if you would like an example. CMS has
done very little of this for Medicare. Not since OTA have they done
systematic reviews.

As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.

allan.
Islander
2009-09-15 15:03:21 UTC
Permalink
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
Post by Allan
One of the examples cited in Gary's 10 is about technology - CAT and
MRI. MRI's are much better (more effective) in detecting small tumors
than traditional x-rays. CAT scanners are much better in evaluating
soft tissue injuries (sports injuries as an example) than x-rays. But
the argument is made that it is "wasteful" - and as such Comparative
Effectiveness data would suggest to use them and cost-effectiveness
likely would tell you not. I have plenty of other examples if you
like.
Here is a remarkably frank commentary from a conservative friend from Texas:
"Texas has a culture where clinics in small towns are owned by the
doctor’s. They are god awful in the management of their clinics, so
they simply charge more to offset their inefficiency. They also tend to
egomania, and are gadget freaks, so they purchase as many CAT scanners
or MRIs as possible, and offset the charges by using the devices as
often as possible. They also own or organize the nurse’s aid groups,
have a piece of the pharmacy, and can write off for the iRS everything
but the kitchen sink to the clinic."

I am guessing that Comparative Effectiveness analysis will not change that.
Post by Allan
Post by Islander
Frankly, I'm surprised that the insurance industry is not supporting
comparative effectiveness. Perhaps they have simply lost control of
their mobs.
The insurance industry - more specifically the medical managed care
industry - does use comparative effectiveness - moreover, they use
cost-effectiveness - you need to read the AMCP guidelines on dossier
submissions for pharmaceuticals if you would like an example. CMS has
done very little of this for Medicare. Not since OTA have they done
systematic reviews.
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex? It is clear to me that we cannot trust the health insurance
industry. While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias. It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen. Who is the
knowledgeable, yet impartial advocate for the public?
Allan
2009-09-15 20:13:49 UTC
Permalink
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.

All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.

So instead of case finding, now we have cost per case found.
Post by Allan
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.

The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).

allan
Islander
2009-09-16 14:10:51 UTC
Permalink
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Islander
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Islander
Post by Allan
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex?
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
Post by Islander
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
Post by Islander
While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
Post by Islander
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Post by Islander
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up. Are you familiar with it?

What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
Evelyn
2009-09-16 14:15:05 UTC
Permalink
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Islander
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Islander
Post by Allan
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex?
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
Post by Islander
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
Post by Islander
While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
Post by Islander
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Post by Islander
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up. Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
That does sound like a good idea.
--
Evelyn

"Even as a mother protects with her life her only child, So with a boundless
heart let one cherish all living beings." --Sutta Nipata 1.8
Allan
2009-09-16 23:48:06 UTC
Permalink
Post by Islander
Post by Allan
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite.  Comparative effectiveness
looks only at one parameter - the outcome.  For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets.  Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices.  The metric used is called the incremental cost effectiveness
ratio (ICER).  The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness.  Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Allan
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable.  One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments.  Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable.  The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic.  I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus.  Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public.  Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up.  Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management. We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot. Worked fairly well except
patients (many of them elderly) didn't like the idea. They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.

In 2004-5 they moved to the current system. It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric. Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem. That, and the population isn't that keen on the new system.

If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls. It is
universal but that's about it. As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.

allan
Islander
2009-09-17 14:37:17 UTC
Permalink
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Islander
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Islander
Post by Allan
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex?
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
Post by Islander
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
Post by Islander
While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
Post by Islander
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Post by Islander
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up. Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management. We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot. Worked fairly well except
patients (many of them elderly) didn't like the idea. They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system. It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric. Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem. That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls. It is
universal but that's about it. As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.

I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Rumpelstiltskin
2009-09-17 15:31:39 UTC
Permalink
On Thu, 17 Sep 2009 07:37:17 -0700, Islander <***@privacy.net>
<snip>
Post by Islander
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
The way to make sure we never find out if a public
option can control costs better than private coverage
is to see to it that a public option is never tried.
Allan
2009-09-17 19:54:46 UTC
Permalink
Post by Rumpelstiltskin
<snip>
Post by Islander
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
   The way to make sure we never find out if a public
option can control costs better than private coverage
is to see to it that a public option is never tried.
You have two models - Medicare and Medicaid - go for it. Start
squeezing.

You have over a million Federal employees with 3 million total covered
lives - start with them - public option and start squeezing. Show
people it can work and they will be beating a path to your door.

Why hasn't anyone thought of this?

allan
allan
Allan
2009-09-17 15:49:02 UTC
Permalink
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite.  Comparative effectiveness
looks only at one parameter - the outcome.  For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets.  Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices.  The metric used is called the incremental cost effectiveness
ratio (ICER).  The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness.  Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Allan
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable.  One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments.  Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable.  The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic.  I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus.  Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public.  Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up.  Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management.  We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot.  Worked fairly well except
patients (many of them elderly) didn't like the idea.  They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system.  It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric.  Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem.  That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls.  It is
universal but that's about it.  As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings. More health care, more access, more technology, happier
patients, that is the inferred remit. Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required. In fact, direct negotiation
between payers and providers is infrequent. Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
Post by Islander
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement. A public option doesn't
change anything other than where the money comes from. The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model. When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion. When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.

The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again. She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments. If you may recall, Erasmus University is
a hot bed of HTA work and has been for years. She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization. That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control. They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.

The last thing is that they are starting (again) to do "soft"
rationing. Unavoidable in her mind. It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.

allan
Islander
2009-09-17 17:12:53 UTC
Permalink
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Islander
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Islander
Post by Allan
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex?
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
Post by Islander
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
Post by Islander
While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
Post by Islander
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Post by Islander
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up. Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management. We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot. Worked fairly well except
patients (many of them elderly) didn't like the idea. They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system. It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric. Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem. That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls. It is
universal but that's about it. As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings. More health care, more access, more technology, happier
patients, that is the inferred remit. Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required. In fact, direct negotiation
between payers and providers is infrequent. Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
Post by Islander
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement. A public option doesn't
change anything other than where the money comes from. The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model. When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion. When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.
The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again. She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments. If you may recall, Erasmus University is
a hot bed of HTA work and has been for years. She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization. That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control. They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.
The last thing is that they are starting (again) to do "soft"
rationing. Unavoidable in her mind. It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.
allan
It is not clear how the public option might be implemented, if it
survives, but to claim that it is a public welfare subsidy model is not
only premature, but not what has been proposed. Your political bias is
showing!
Allan
2009-09-17 17:50:19 UTC
Permalink
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite.  Comparative effectiveness
looks only at one parameter - the outcome.  For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets.  Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices.  The metric used is called the incremental cost effectiveness
ratio (ICER).  The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness.  Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Allan
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable.  One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments.  Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable.  The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic.  I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus.  Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public.  Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up.  Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management.  We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot.  Worked fairly well except
patients (many of them elderly) didn't like the idea.  They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system.  It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric.  Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem.  That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls.  It is
universal but that's about it.  As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings.  More health care, more access, more technology, happier
patients, that is the inferred remit.  Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required.  In fact, direct negotiation
between payers and providers is infrequent.  Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
Post by Islander
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement.  A public option doesn't
change anything other than where the money comes from.  The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model.  When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion.  When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.
The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again.  She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments.  If you may recall, Erasmus University is
a hot bed of HTA work and has been for years.  She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization.  That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control.  They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.
The last thing is that they are starting (again) to do "soft"
rationing.  Unavoidable in her mind.  It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.
allan
It is not clear how the public option might be implemented, if it
survives, but to claim that it is a public welfare subsidy model is not
only premature, but not what has been proposed.  Your political bias is
showing!
The public welfare subsidy model is not a political statement, it was
a statement of fact based on simple economic principles and how it was
written into HR3200. Sorry you took offense that the inference was
one that it is "bad" and I was against it.

The term Public Welfare is used to describe who manages (government)
and how money's are collected and distributed - Public is defined as
by an arm of the government, and Welfare is the redistribution based
on need as opposed to contribution. That's how HR3200 wrote in the
"public option". See section 222 and 241. Much of the rest is also
based on a welfare model. If everyone paid their own way then we
wouldn't be having this discussion - but that isn't the case and we
all know it.

The entire industrialized world is facing the same problem in health
care - no system is immune from the increased expenditures for health
care. The reasons are multifactorial but boil down to three basic
things - - more people using more stuff that is more expensive.
Three ways to fix it - less people, less stuff, or less cost. Three
strategies - pull the plug on grandma, ration access to stuff, or fix
prices. Each comes with its own set of "externalities" as the
economists like to say.

Writing fancy bills that move money around is not the solution. Time
for us to come to grips with reality.

Allan
Islander
2009-09-17 18:29:36 UTC
Permalink
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality. It is politics. The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Islander
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this. From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite. Comparative effectiveness
looks only at one parameter - the outcome. For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets. Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices. The metric used is called the incremental cost effectiveness
ratio (ICER). The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness. Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Islander
Post by Allan
As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.
allan.
Yes, you work in the field. It does raise an interesting question,
however. How is the average person supposed to deal with a system this
complex?
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
Post by Islander
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable. One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments. Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable. The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
Post by Islander
While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.
No – I am not biased, I am pragmatic. I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
Post by Islander
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.
The Whitehouse has an agenda that is driven by something other than
consensus. Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public. Hence my first point.
Post by Islander
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up. Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management. We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot. Worked fairly well except
patients (many of them elderly) didn't like the idea. They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system. It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric. Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem. That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls. It is
universal but that's about it. As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings. More health care, more access, more technology, happier
patients, that is the inferred remit. Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required. In fact, direct negotiation
between payers and providers is infrequent. Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
Post by Islander
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement. A public option doesn't
change anything other than where the money comes from. The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model. When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion. When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.
The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again. She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments. If you may recall, Erasmus University is
a hot bed of HTA work and has been for years. She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization. That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control. They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.
The last thing is that they are starting (again) to do "soft"
rationing. Unavoidable in her mind. It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.
allan
It is not clear how the public option might be implemented, if it
survives, but to claim that it is a public welfare subsidy model is not
only premature, but not what has been proposed. Your political bias is
showing!
The public welfare subsidy model is not a political statement, it was
a statement of fact based on simple economic principles and how it was
written into HR3200. Sorry you took offense that the inference was
one that it is "bad" and I was against it.
The term Public Welfare is used to describe who manages (government)
and how money's are collected and distributed - Public is defined as
by an arm of the government, and Welfare is the redistribution based
on need as opposed to contribution. That's how HR3200 wrote in the
"public option". See section 222 and 241. Much of the rest is also
based on a welfare model. If everyone paid their own way then we
wouldn't be having this discussion - but that isn't the case and we
all know it.
The entire industrialized world is facing the same problem in health
care - no system is immune from the increased expenditures for health
care. The reasons are multifactorial but boil down to three basic
things - - more people using more stuff that is more expensive.
Three ways to fix it - less people, less stuff, or less cost. Three
strategies - pull the plug on grandma, ration access to stuff, or fix
prices. Each comes with its own set of "externalities" as the
economists like to say.
Writing fancy bills that move money around is not the solution. Time
for us to come to grips with reality.
Allan
Words carry implications and the words one chooses bias a discussion.
To describe the public option as a "public welfare subsidy model" seems
to me to be a choice of words that is intentionally inflammatory and
misleading.

I also take exception to your three basic things. That is a fixed size
pie argument and ignores efficiencies that can be achieved by covering
everyone and eliminating the waste, fraud and abuse that are inherent in
our current system.

Paying twice as much per capita for our health care for arguably poorer
outcome than that found in other industrialized countries having various
forms of universal health care speaks volumes to me.
Rita
2009-09-17 19:07:35 UTC
Permalink
Post by Islander
Words carry implications and the words one chooses bias a discussion.
To describe the public option as a "public welfare subsidy model" seems
to me to be a choice of words that is intentionally inflammatory and
misleading.
I also take exception to your three basic things. That is a fixed size
pie argument and ignores efficiencies that can be achieved by covering
everyone and eliminating the waste, fraud and abuse that are inherent in
our current system.
Paying twice as much per capita for our health care for arguably poorer
outcome than that found in other industrialized countries having various
forms of universal health care speaks volumes to me.
Allan purports to be totally uninfluenced by any ideological
preferences. If he is, he is a unique human being. That claim raises
a red flag with me whoever it is that makes it.

The totally impartial observer does not exist.
Allan
2009-09-17 19:48:44 UTC
Permalink
Post by Rita
Post by Islander
Words carry implications and the words one chooses bias a discussion.
To describe the public option as a "public welfare subsidy model" seems
to me to be a choice of words that is intentionally inflammatory and
misleading.
I also take exception to your three basic things.  That is a fixed size
pie argument and ignores efficiencies that can be achieved by covering
everyone and eliminating the waste, fraud and abuse that are inherent in
our current system.
Paying twice as much per capita for our health care for arguably poorer
outcome than that found in other industrialized countries having various
forms of universal health care speaks volumes to me.
Allan purports to be totally uninfluenced by any ideological
preferences.  If he is, he is a unique human being.  That claim raises
a red flag with me whoever it is  that makes it.
The totally impartial observer does not exist.
Think you could comment on the content written as opposed to your
presumptions of impartiality?

No? - good. then I'll stop reading what you write.

allan.
Allan
2009-09-17 19:44:29 UTC
Permalink
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Islander
Post by Allan
Post by Allan
Post by Islander
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Post by Allan
Post by Islander
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite.  Comparative effectiveness
looks only at one parameter - the outcome.  For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets.  Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices.  The metric used is called the incremental cost effectiveness
ratio (ICER).  The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness.  Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
Post by Allan
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable.  One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments.  Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable.  The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic.  I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus.  Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public.  Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up.  Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management.  We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot.  Worked fairly well except
patients (many of them elderly) didn't like the idea.  They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system.  It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric.  Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem.  That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls.  It is
universal but that's about it.  As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings.  More health care, more access, more technology, happier
patients, that is the inferred remit.  Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required.  In fact, direct negotiation
between payers and providers is infrequent.  Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
Post by Islander
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement.  A public option doesn't
change anything other than where the money comes from.  The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model.  When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion.  When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.
The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again.  She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments.  If you may recall, Erasmus University is
a hot bed of HTA work and has been for years.  She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization.  That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control.  They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.
The last thing is that they are starting (again) to do "soft"
rationing.  Unavoidable in her mind.  It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.
allan
It is not clear how the public option might be implemented, if it
survives, but to claim that it is a public welfare subsidy model is not
only premature, but not what has been proposed.  Your political bias is
showing!
The public welfare subsidy model is not a political statement, it was
a statement of fact based on simple economic principles and how it was
written into HR3200.  Sorry you took offense that the inference was
one that it is "bad" and I was against it.
The term Public Welfare is used to describe who manages (government)
and how money's are collected and distributed - Public is defined as
by an arm of the government, and Welfare is the redistribution based
on need as opposed to contribution.  That's how HR3200 wrote in the
"public option".  See section 222 and 241.  Much of the rest is also
based on a welfare model.  If everyone paid their own way then we
wouldn't be having this discussion - but that isn't the case and we
all know it.
The entire industrialized world is facing the same problem in health
care - no system is immune from the increased expenditures for health
care.  The reasons are multifactorial but boil down to three basic
things - - more people using more stuff that is more expensive.
Three ways to fix it - less people, less stuff, or less cost.  Three
strategies - pull the plug on grandma, ration access to stuff, or fix
prices.  Each comes with its own set of "externalities" as the
economists like to say.
Writing fancy bills that move money around is not the solution.  Time
for us to come to grips with reality.
Allan
Words carry implications and the words one chooses bias a discussion.
To describe the public option as a "public welfare subsidy model" seems
to me to be a choice of words that is intentionally inflammatory and
misleading.
It is an ECONOMIC definition. I don't make this shit up - it is how
it is defined in the economic literature. The definitions are precise
and accurate - not inflammatory or misleading. You are the one
inferring something that isn't there.

It is a PUBLIC system - and that is defined as one which uses the
PUBLIC sector to plan, implement, and control.
It is a Welfare subsidy model - it uses redistribution of funds to
subsidize those who cannot pay from funds collected from those who
can. It doesn't matter if it is in premium redistribution, general
revenue redistribution, or whatever. It is the definition of the
term. You want the label to connote something regarding politics,
that is your problem, not mine. Only bigots and illiterates think
welfare is a four letter word.
Post by Islander
I also take exception to your three basic things.  That is a fixed size
pie argument
I never made a fixed pie argument - the fixed pie argument is one that
is being made by the President when he says we are spending TOO much
on health care and we need to reverse that.
Post by Islander
and ignores efficiencies that can be achieved by covering
everyone
Define efficiencies in a way they cannot be categorized as

less people, less
less stuff, or
less cost.

You can't. Economies of scale are at the margin, and not at the
total. This is the economics not the politics. Look it up if you
like. The only time economies of scale reduce the total cost is if
the marginal cost is less than zero.
Post by Islander
and eliminating the waste, fraud and abuse that are inherent in
our current system.
What makes you think waste and fraud are going to disappear by
changing the system of financing and if you believe it can, why do we
need to change the system of financing to accomplish it? And it
doesn't fix the problem either - when the problem is defined as
expenditure growth. You may be able to reset the clock but it does
NOTHING to change the dynamic - less people, less stuff, less cost
(though I should have said less price, but that is grammatically
incorrect).

And as for abuse - if you define an MRI and a SMAC 20 as an abuse for
a hangnail treatment, you just fell into the "less stuff" box.

Quit trying to infer that somehow I am not on your side on this. I
think health care sucks the world over - we can and should do better.
I've played in these systems my entire professional life and have seen
far too much first hand NOT to question the proposals - and it's not
just Washingtonian spin - it comes out of Labor in the UK and even
from Andrea in Germany. The French are sucking wind on this too. The
Dutch are running around in circles like they did back in 2002-3.
Post by Islander
Paying twice as much per capita for our health care for arguably poorer
outcome than that found in other industrialized countries having various
forms of universal health care speaks volumes to me.
Then you missed the point. Too bad, I really thought you were beyond
the politics of the issue.

You do understand that every large economy in the industrialized world
is facing exactly the same problems with health care and that they
have systems of health care financing that range from none to complete
public universal care. And you must know that every form of health
care financing is trying to fix it one way or another but each and
every one, without exception, is doing it using the three buckets that
I described - if you want the economic nomenclature for them, happy to
oblige - euthanasia, rationing, tariffs. Want the Obamacare words?
Sure - end of life counseling, improved efficiency and quality, and
outcome based reimbursement.

Ask the Dutch how well #1 worked. Ask the Brits how #2 works for
them, and then ask the Germans how IQWiG is working for them - becuase
that puts all three on the table at once.

Oh well - lesson learned.

allan
El Castor
2009-09-13 06:03:40 UTC
Permalink
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Always good to know what Obamacare is really all about. As for #2, I
have a brother-in-law who would have died four years ago were it not
for three stents. I'm sure he would be thrilled to know that he should
have been treated with diet in the ER, rather than defibrillated four
times.
Gary
2009-09-13 11:50:01 UTC
Permalink
Post by El Castor
Post by Gary
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Always good to know what Obamacare is really all about. As for #2, I
have a brother-in-law who would have died four years ago were it not
for three stents. I'm sure he would be thrilled to know that he should
have been treated with diet in the ER, rather than defibrillated four
times.
I don't profess to have answers. But this idea of "preventative
medicine" is beginning to interest me. It seems to me the doctors
these days spend more time "preventing" than they do healing.
Which may all be well and good. But ...... some prevention is very
invasive.
Emily
2009-09-13 13:05:54 UTC
Permalink
Post by El Castor
Post by Gary
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
Always good to know what Obamacare is really all about. As for #2, I
have a brother-in-law who would have died four years ago were it not
for three stents. I'm sure he would be thrilled to know that he should
have been treated with diet in the ER, rather than defibrillated four
times.
My husband might have died had he not gotten two stents via
angioplasty -- but he was in the ER after a heart attack as apparently
was your brother-in-law. I don't know if those 1,000,000 procedures
the author mentions are all done in emergency situations. Some are
probably done prophylactically and it would be hard to determine if
they are all actually necessary or if other treatments would be just
as effective.
El Castor
2009-09-14 00:24:26 UTC
Permalink
Post by Emily
Post by El Castor
Post by Gary
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
Always good to know what Obamacare is really all about. As for #2, I
have a brother-in-law who would have died four years ago were it not
for three stents. I'm sure he would be thrilled to know that he should
have been treated with diet in the ER, rather than defibrillated four
times.
My husband might have died had he not gotten two stents via
angioplasty -- but he was in the ER after a heart attack as apparently
was your brother-in-law. I don't know if those 1,000,000 procedures
the author mentions are all done in emergency situations. Some are
probably done prophylactically and it would be hard to determine if
they are all actually necessary or if other treatments would be just
as effective.
One of the concepts being used to sell healthcare reform is the idea
that increased preventive medicine will reduce the cost of healthcare.
I read some comments on that awhile back, and it was the author's
contention that preventive medicine didn't decrease the cost of
healthcare -- it increased it. "X" number of mammograms will in turn
generate "X" number of biopsies, but only find one case of breast
cancer. Skipping the mammograms/biopsies and waiting for that one case
to develop symptoms, and then get treated, will save a ton of money
spent on "unnecessary" tests and biopsies. The only problem with that
approach is that the one woman who does have cancer will probably be
found much later in the progression of the disease, and consequently
will be at increased risk of dying. Not coincidentally, the following
tables from the London Telegraph show that five year survival rates
for cancer are higher in the United States, than in Europe.
http://www.telegraph.co.uk/news/uknews/1560849/UK-cancer-survival-rate-lowest-in-Europe.html

So, is it worth the extra expense to save that one woman? I think it
is, and the author of the article that I read, agreed. He was an
economist, and believed that as long as our economy continued to grow
at a reasonable pace, we could afford it. The question is -- will the
politicians in DC allow us to afford it?
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