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ifthenelsenull (36.63)

the healthcare debate continued



March 21, 2007 – Comments (4)

This is a reply to a reply to one of my posts called healthcare for all.. if that's not too confusing read on.




            Thanks for reading and writing.  I was wondering if anyone was actually reading this but apparently you are.  I love how you muddy the water because it keeps me sharp.  I don’t remember if I posted my review of why medicine is basically a weird combination of socialism and capitalism where everyone gets what they need to not die and then overpays for it.  If not I’ll post it later if so… well… then I posted it. 


Anyway last things first.  Pages 56, 57 and 58 (pages 68-69-70 on the PDF.  I will continue to put PDF. References in parenthesis) are examples of higher satisfaction rates exhibited by Medicare patients vs. Medicaid patients vs. Private insurance.  I will say that yes they do indicate that Doctors are satisfying more slightly more Medicare patients than the other covered patients.  What I believe is happening here is simply related to expectation.  The elderly are comfortable with waiting a long period of time for a short interaction; privately insured patients are generally younger and have a different expectation of value and Medicaid patients have a sense of entitlement since they are already on the receiving end from the Government.


 The data seems to agree with that assessment and although you can’t cookie cutter it that easily I think that it may explain some variety.  Page 56 appears to me to be about 52%, 54% and 58%.  This is not an amazing difference and in reality that number alone is shameful.  So you basically flip a coin and that determines if you’ll get timely care.  It’s absolutely true but still terrible.  I think the chart on page 57 should have displayed in the opposite direction but that’s not my prerogative.  The chart says similar things although the Medicaid component is flipped probably giving a bit less credibility to my previous hypothesis.  Still 58% to about 68% in the grand scheme of satisfaction doesn’t appear to indicate a particularly strong job being done.  The chart on page 58 (70) to me is significant.  The Medicare patients indicate that they get better care probably about 20% more than the private insurance.  However the real question here is do they get the care they seem to indicate?  Obviously they are very wrong in their assessment of the system.  Page 48 (60) indicates that the care received by the elderly, who are very often Medicare patients is terrible.  I’ll excerpt the bullet points here.

 The percentage of quality standards met varies for different types of care■ Standards were met least often for preventive care—43 percent of the time. Standards met for diagnosis were only slightly higher at 46 percent■ Standards were met most often for treatment (80 percent)■ This difference might be explained by the nature of the U.S. health care system, which reimburses providers for time spent performing procedures and prescribing medications, but not for time spent taking thorough histories or providing preventive counseling■ Researchers also found that providers administered proper care to patients with conditions that needed immediate treatment (acute conditions) far more frequently than to those with chronic health problems—83 percent of the time versus 51 percent


In summary the care being provided to the elderly sucks.  There is no way to sugar coat that.  The government (Medicare) pays the providers for doing not caring.  Almost all insurers follow a standard which is known as Local Medicare Review Policy or LMRP.  This basically compares the International Statistical Classification of Diseases and Related Health Problems commonly known as ICD-9 (diagnosis in number format) with the Current Procedural Terminology which is most commonly known as CPT and is a number which corresponds to a test or procedure that you order or perform.  So in reality the private insurance might pay slightly more than Medicare but they basically pay for the same things.  Since doctors are still based mostly on paper they have to have a coder to determine what is covered for what or know it on their own.  Commonly this results in a claim denied letter because your doctor chose the wrong ICD-9 for your test.  So I don’t believe in anyway shape or form is the care provided to Medicare/Medicaid particularly superior to that provided by private insurance.  In a nutshell the reason private insurance companies pay doctors slightly more than Medicare/Medicaid is they can’t force you to take on their patients (unlike the government) and if they don’t have doctors taking their payments they have no one to send their clients to and the clients don’t renew resulting in lost revenues etc…


Page 41 (53) is significantly more disturbing than even the previous information.   

 RAND’s national study found deficits in quality of care across all types of care—chronic, preventive, and acute■ Recommended care for managing chronic conditions (e.g., diabetes and hypertension) was provided 56 percent of the time■ Preventive care (e.g., flu shots, mammograms and smoking cessation counseling) met quality standards 55 percent of the time■ Recommended care for acute health problems (e.g., pneumonia and urinary tract infections) was provided 54 percent of the time 

These are well established issues that are simply not getting done with any greater regularity than a coin flip.  Seriously people are not getting flu shots, mammograms and being told to stop smoking?  The answer to that is yes and it’s painfully obvious. 


            The system is somewhat business run but in the end it is still government run.  The government keeps up significant barriers to entry which fails to allow competition and serve to keep prices artificially high.  I know it appears to be privately run but care standards are established by someone other than the doctor, payment levels are set by someone other than the doctor and setting up a practice requires extensive government involvement. 


The rand report indicates the exceptional and widespread failures of the system but I would agree that seeking treatment less often is not an adverse health effect.  Of course not going to the doctor is an adverse health effect especially when you have an undiagnosed illness that gets worse.  My solution is not to increase co-pays which is simply increasing the hassle factor and attempting to discourage use but to continue to introduce real free markets.


 I love concierge medicine and think it is an excellent solution to some of the ills now plaguing the system.  (Disclaimer my Doctor is a Concierge Physician)  Before anyone jumps in with the worn out argument that this is discriminatory against the poor… yes it is absolutely and without apology.  The current system is rationed by time with means it is costly enough the solution is to ration care by money.  This is the real solution because it means that the tide can change.  There are less and less people becoming doctors and why is that you ask.  Well because working like a dog 7 days a week for only 120K after all that schooling is a waste when they can go to Wall St. and do that for an investment bank and get paid much better.  How do we get more doctors up the pay and decrease the hassle factor leading them to actually provide care for their patients rather than herding them like cattle.  If you don’t like things being rationed by money then there is a nice island nation where that’s not happening… hint you can take a short boat ride there.  Here’s something else rationed by money Porsches.  I want one but I can’t afford it (yet).  So I have a Toyota Yaris which I love and is awesome on gas.  The really poor don’t have a Yaris and especially not a Porsche but do we really care about that?  Porsches and S-Classes are elitist but don’t we all want them.  Possibly included in that is the Venti Soy Vanilla Latte I love so much.  Simple economics indicates that money talks. 


Oh and here’s something that is not in the Rand report… my doctor would score 100% on all the care standards because he’s not overworked and actually has time to care for his patients.  Can I get timely care… sure I call his cell phone and he’ll make a house call if necessary.  Sure there is some cost sharing, I pay him.  However the reward is that I go pretty much every month just to check in and see how I’m feeling, I never wait in a waiting room, and my appointments are never less than an hour.  You’re probably saying how can I get that?  I’m saying you probably can’t because the socialists in the system want to keep you from getting good care.  It’s like saying because the poor can’t afford Porsches no one should have them.  The poor get bad medical care so you should too.  I say absolutely not to that.  Before my current physician I didn’t really go to the doctor because I’m not cattle and I will not be herded into a waiting room full of people coughing on me and sit there for an hour when I made an appointment.  I will not be seen for 5-10 minutes poked/prodded and given 1 minute to voice any concerns.  I have seen the light on the other side and understand the value of a dollar.  This is an example of where private business hammers the government left, right and center. 


Steven I appreciate your comments because they are always so challenging and keep me thinking.  Like always we are in the same pond probably near the middle just on slightly different sand bars. 


4 Comments – Post Your Own

#1) On March 21, 2007 at 2:46 PM, ricoy5 (25.62) wrote:

my first comment got lost, so here goes again.

For me, the why of social health care is not as much because it's right (I think so) but that it's smart.  If our society is based on captialism and survival of the fittest, isn't a big part of that ensuring that those less well off don't get neglected and disenfranchised to the point that they eventually engage in open class war?

Our health and education systems are leaning this way.  the rich (and middle class that pony up) are going to private schools and paying cash for better health care (or being better educated, which allows us access to better employers who provide insurance worth a damn)

If expanding this divide is the goal, then we're doing a bang up job.  But shouldn't another goal be to preserve our soceity for the long term, and that does mean providing a basic service to all.

We do it with the legal system.  Public defenders provide a BASIC service to those not able to afford "concierge legal".  Is it great? no. Does it prevent those poor from being COMPLETELY screwed? in theory.  Have we decided that this is a basic right for all those living (legaly?) in our society.  DEFINATELY.

So why not health care? On the same general principal, provide BASIC preventative medicine and health screening to all... 

An army of doctors (paid 40-50K like residents, but incentivised through loan-repayment grants) would go to places of work, schools, local clinics, etc.  Provide a yearly checkup, health screen, (hey, maybe even prescribe free penecillin).  Free EKG and CT scans this is not. 

Everyone gets free health screening, a basic level of wellness is ensured for all, reducing the burdon on our hospital system.

Those who can pay (or work for employers who provide) better insurance, can get access to specialists, treatments, etc.  You want to pay cash for even better and quicker service, go for it.

Altruistic, yes. 

Fiscally doable? Probably not.  but at least more so than the "free health care for all" crap that's gaining traction again. 

Better health care for all?  It's a place to start.  And it's not going to make it worse for those with insurance/cash like a universal plan would.

My wife likes this idea... She's a MD who's gonig to join a cash only practice, because she's tired of being paid 12 cents on the billable dollar, and making 20% more revenue off of co-pays than from re-imbursement.

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#2) On March 21, 2007 at 8:07 PM, ifthenelsenull (36.63) wrote:



            Thanks for your post.  I do think you are missing my point though.  I’m really not a Social Darwinist.  I am a free market economy guy and truly believe in helping the poor.  Believe me donating to charity is a huge thing in my house.  However I don’t think we need to simply give, incent, or subsidize to make equality.  History has shown that income transfers don’t work and I’m seeing into the future here but they won’t work there either.  I am 100% for providing a basic service.  It’s like giving everyone a Chevrolet Aveo, sure it’s not too cool but it gets it done.  I would never be for giving everyone a Porsche because frankly that’s earned not given.  Metaphorically speaking anyway.  I am 100% for the free market entering medicine.  Sure the poor won’t benefit amazingly but they get the side benefit.  If you let the people who can afford to pay their way simply do that then the poor will have more spots in Doctors offices. 


Many doctors really just want to care for people make a reasonable living and really change lives.  For them the current system works ok but they are obviously overburdened.  How can we lighten the load while allowing the free market to work?  Concierge medicine to me seems to be the best solution.  Not to discourage your wife but I think concierge is better than cash only depending on the area you live in.  If it’s affluent enough and especially if it’s the self-employed then maybe cash only is the way to go but maybe not.  Like everything in life there is no cookie cutter solution I like the concierge model because it combines insurance and cash.  They start with a retainer and then bill your insurance company.  This takes advantage of the largest possible pool of patients.  The upper middle class through the ultra wealthy clientele includes a fairly large number of people my area.  This is important because cash only is likely to decrease number of visits if you are billing by the visit and the patient pool.  Always remember people like the feeling of getting their moneys worth and using their insurance.  Still this doesn’t correct the massive billing imbalance on what you would pay cash for and what the insurance will find reasonable and customary.   


Healthcare and legal representation are considered basic rights in our society no matter what your legal status.  That is why we have things like medical tourism.  Can we afford to go socialist?  I don’t think so because we already have a massive expenditure of about 12% of GDP.  The beaucracy is already way too expensive.  Doctors don’t practice much medicine these days most of them simply perform CYA medicine.  Again not everyone but the most prevalent reason I hear for performing any exam, test or procedure it to avoid litigation.  So a basic physical exam might consist of the physical a slew of blood work, maybe a chest x-ray (depending on Diagnosis).  It might also consist of other exams.  Who gets to define the basic level?  If you have any doubt check out an ER.  Now the EMTALA standard requires that if you are having an emergency or in labor that you get an examination by a medical professional.  However it in no way shape or form guarantees you MRIs. CT scans, treatment for your hangnail or evaluation of your last 10 years of back pain.  I absolutely guarantee that if you show up at your local ER you’ll get whatever treatment is available (not always warranted, but available) and they’ll tell you that EMTALA requires them to MRI the sore neck of the gentleman “visiting” his family from Bolivia “just in case” the last 10 years have been an anomaly.  Oh on that one I can absolutely verify that occurrence.  The basic will never be enough because in the Rand report we see how the basics aren’t getting done now and once they start it will be even more CYA. 


I’m simply stating that we should allow those who can and are willing to pay the opportunity to do so.  Currently in Connecticut the politicians and attorneys are sitting back and saying well we’re watching.  I’m saying cut the nonsense out and let the market take over.  All this talk about equality is nonsense.  There is no such reality available here in the U.S. we aren’t communists or socialists… no matter what the representatives from California and MA want us to believe. 


I still don’t see why we need an army of underpaid physicians.  Physicians are highly educated and should be paid for that.  I think that allowing for free markets will mean there will be more physicians coming into practice and those who are good will excel in the market.  I think that the basic premise I have is significantly better than anything I am hearing from the talking heads and elected liars.  Let me know if this is a bit more clearly stated.  I wish your wife the best and am sure that she’ll experience medicine as she imagined it really would be. 



- Chris      

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#3) On March 23, 2007 at 4:25 PM, ricoy5 (25.62) wrote:


this makes sense, but the market does not always fill everyone's need... Who is going to provide basic healthcare for someone who isn't going to pay you?  The free market will provide numerous creative alternatives for the upper middle class... but the masses (especially the uninsured) will have no one to treat them... unless you keep subsidzing the treatment through medicare, medical, etc...

Anyhow, I'm going to look up a few more instances of concierge service that you mentioned, it might be something that her new practice can elplore. 

and I appreciate the discussion, I find huge topics like this enthralling, there is so much to uncover and learn, and even somone stating facts that you already know (CYA) are enlightening. 

til next time.

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#4) On March 24, 2007 at 10:23 AM, ifthenelsenull (36.63) wrote:

Ricoy,          This is where people go seriously wrong.  Someone is going to pay you... a reasonable rate.  Quick review who name the largest companies that cater to the wealthy... now name 2 that cater to the poor (or at least not wealthy).  If your like most people you had a hard time defining who was the preeminent name in providing goods to the wealty but immedately came up with Wal-Mart and IKEA.  If there is an opportunity and the ability to take it the market will provide.  There are way more poor people than there are wealthy.  The poor care about their health but don't see the value in taking an entire day off from work and then being seen for 15-30 minutes and being told to come back in a year.  I too would find that to be a poor value.  Physical exams to the poor might be worth $20 which oddly enough might be the current co-pay.  I wouldn't begin to worry about the potential for all doctors to decide that they are going to be concierge.  The markets are fairly efficient and someone graduated last in their class from medical school.  Some will operate in the concierge market and others in the volume market.  There will be care for all.  In my area current concierge rates range from $1000 -$2500 a year.  Sure the doctors charging less might take on more patients but in the end they get better care leading to better outcomes.  I'm currently working on a book so I won't be posting the full equations here (lest I devalue my book) :-).  
        I'm also not saying that we shouldn't subsidize care especially for now.  Maybe it should be decreased over the years as more doctors come online and the market continues to evolve. I think by taking the wealthy and those willing to pay out of the current system we can lighten the load and encourage more people to become doctors.  I think this is a huge area of concern for those who are willing to think and talk about it and not just make political grandstand remarks like some who have been elected.  This is why I love the boards.  Thanks for the reply.

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