2781

I hear where you are coming from, which is why I was careful to write “cured/cureable maligancy.”

I have a difficult time imagining a patient with a cureable malignancy (which otherwise would take a person’s life) and deciding on a significantly inferior treatment plan because of cost concerns. Sometimes the options are all about the same of course, and sometimes there are other considerations (e.g. religious, extremely advanced age). But, when we’re talking about a cureable malignancy, if you’re not going to swing for the fences in that circumstance, then when are you?

Before anyone reads too much into that, I’m just talking about cureable malignancies and not incurable malignancies (which there are too many of) or any other type of acute or chronic illness.

2782

The counter example is pretty obvious:

Instead of just giving you a hospital and telling you to treat whomever comes in with enough insurance or money to pay I give you a hospital, some money and tell you to do the best you can with both. A costs $10,000. B costs $1,000. A has a 99% cure rate and B has a 90% cure rate. You have $1,000,000 and 1,000 patients. Which do you use? If you use A then how do you justify the fact that you could have cured 801 more people?

Either way, we’re deviating from my point: doctors need to be on the same side of the ledger as patients. Our current system creates financial motivation to perform treatments but not to maximize outcomes or minimize cost. Perfect doctors may still perform well under those circumstances but it shouldn’t be surprising that average doctors and bad doctors often do poorly and a lot of our healthcare inefficiencies stem from these average/worst cases of doctors who end up over-medicating and over-testing and don’t get better results even though they’re spending way more.

2783

Interesting hypothetical. I’m not sure I should start talking about that here, so I’ll refrain unless others show interest.

Either way, we’re deviating from my point: doctors need to be on the same side of the ledger as patients. Our current system creates financial motivation to perform treatments but not to maximize outcomes or minimize cost. Perfect doctors may still perform well under those circumstances but it shouldn’t be surprising that average doctors and bad doctors often do poorly and a lot of our healthcare inefficiencies stem from these average/worst cases of doctors who end up over-medicating and over-testing and don’t get better results even though they’re spending way more.

You mention numerous factors - economic cost to the patient, economic cost to society at large, maximize health outcome, financial incentive for the physician. As you’re already aware, those factors are sometimes at cross purposes from each other. When they are, some guiding principle has to decide which trumps the others. In this country it’s been the well-being of the patient (I’m not saying they always adhere to it correctly, naturally).

Maximizing health outcome is a great goal. I’m entirely supportive of it. Measuring it and in particular, measuring performance has turned out to be a lot more difficult to do in practice. Some progress is being made with initiatives like One Hundred Thousand Lives, but there is yet a long ways to go.

Whatever system we use up will have some incentives for the physician.

I practice in academia where the incentives can be quite different from private practice. Here is something that happened at work today. I’m seeing a patient in clinic that needs a colonoscopy since I’m suspicious his cancer has recurred. It’s not an emergency, but needs to be done sooner rather than later. The patient is understandably anxious about what might be found. I call the gastroenterologist who also works at the same university and he tells me he can do it in three weeks.

There are private practice gastroenterologists who also live in my city. I call one of them next. He can do it on Wednesday (today is Monday). This guy is paid of course for the number of procedures he performs, my academic friend is paid a salary. The patient will receive the same level of care from either, they both have the same technical level of skill. Medicare reimburses the same regardless of who does it. Guess which one the patient likes a lot better?

2784

Unfortunately it’s not a question of it being a better plan, it’s a question of what I can afford. If I can afford care under the new plan, you bet I will. But not being a family of four, it seems like my subsidies will be significantly lower than someone who will end up paying about $125 a month for their insurance through an exchange. Let’s say my subsidies are half of that (which is probably pretty generous) I can’t afford paying $250 a month for insurance on top of my other bills, but I can afford a $750 fine. I know which I’m going to choose.

2785

…And actually out classed by that same 11 year old!

And thanks everyone for the feedback to my earlier questions, very interesting.

2786

Well, that’s your choice. If you’re older than, say, 30 I’d seriously reconsider though; if you come down with something serious you’re looking at bankruptcy or death.

2787

That’s why you set up a market where doctors (and hospitals, and insurance companies) are all lined up with patients when it comes to outcomes. Instead of trying to be really smart and just make all the decisions from central authority (which isn’t impossible: see Europe) you simply create an incentive structure where doctors interests are the same as patients. Right now we clearly don’t have that. I think we have a number of examples in the US of systems where are system is working. Of course they’re pretty much all non-profits with salaried doctors who are employed based only on a standard of healthy outcomes accomplished without spending too much.

Whatever system we use up will have some incentives for the physician.

I practice in academia where the incentives can be quite different from private practice. Here is something that happened at work today. I’m seeing a patient in clinic that needs a colonoscopy since I’m suspicious his cancer has recurred. It’s not an emergency, but needs to be done sooner rather than later. The patient is understandably anxious about what might be found. I call the gastroenterologist who also works at the same university and he tells me he can do it in three weeks.

There are private practice gastroenterologists who also live in my city. I call one of them next. He can do it on Wednesday (today is Monday). This guy is paid of course for the number of procedures he performs, my academic friend is paid a salary. The patient will receive the same level of care from either, they both have the same technical level of skill. Medicare reimburses the same regardless of who does it. Guess which one the patient likes a lot better?
I’m not going to guess because in past conversations I’ve already quoted a lot of literature suggesting that, whatever your anecdote may be leading to, the non-profit guys tend to do it better. Read the article I linked above (again) and you’ll see a few anecdotes about how the guys at Kaiser and the Mayo clinic tend to get around to seeing their patients more quickly and more personally. I have a number of anecdotes of non-profit Kaiser doctors dropping everything for me that I can throw into the pile.

It’s also not surprising to me that you are working in part of the system that seems to be more or less working and you’re paid a salary with no compensation based on amount of treatment given. As I’ve pointed out before: your opinion seems to be rather biased simply because you are in fact working in one of the less- or non-broken corners of medicine. People like to listen to doctor’s opinions about this subject but to be honest, sometimes you guys are the worst possible people to ask. You’re way too close to your small part of the larger picture and part of the problem is that you’re just not trained to think about medicine in terms of costs and benefits in the first place.

2788

Yup. To repeat my scary anecdote: I’ve had somewhere between $50k-100k in work done this past year and a half (age 31-32), all covered by insurance and with access to at least one world class doctor. I can’t imagine where I’d be now without some insurance. Probably not dead, but probably not in a terribly good place either.

2789

2790

The best part is that within six months that’ll be a covered procedure, and soon nobody will be able to deny Marx insurance based on the pre-existing condition of being dead.

2791

Hah, is that defibrillator have a mason symbol on it?

Someone tell the wingies to check their dollar bills.

2792

My absolute favorite thing to come of this.

Republican senators/representatives saying.
“Now your healthcare is in the hands of the bureaucracy, and that isn’t a good thing.”

YOU ARE THE MOTHER FUCKING BUREAUCRACY!!! YOU WILL BE HELPING TO CONTROL THE FUTURE OF OUR HEALTHCARE. HOW DO YOU MAKE THAT ARGUMENT?! YOU ARE A BUREAUCRAT!!

Do they realize how moronic they sound? They are basically ripping on their own job.

Hell, the god damned GOP was the reason this whole fucking bill was caught up in bureaucratic red tape for months. I love how they try to use that label as a term for democrats.

Anyway… bureaucracy is a spelling bee nightmare word.

2793

I’m assuming you know this St. Gabe, but Kaiser is doctor owned. They are a for-profit LLC. Also you need to be careful because what can happen (and happened to me) is that if you are referred out of the Kaiser system, you can be on the hook for additional costs even though Kaiser says they will cover them. I had treatment at Cedar-Sinai and while Kaiser paid the bulk of the cost, Cedar Sinai billed me for the amount Kaiser wouldn’t pay. Kaiser wouldn’t pay it because they felt it was excessive, so I was stuck. And of course no one told me this would happen until AFTER I incurred the costs.

2794

This is what scares me. Especially given that that you can’t be denied for a pre-existing condition. For many people like you, there is no reason to sign for insurance until after you get sick. You can pay the mandate penalty but benefit by signing up for insurance if you get really sick down the road (assuming you don’t need an emergency treatment).

I think the mandate is much too low and a lot of people are going to opt to pay the penalty. There’s a lot of hope that behavioral economics comes into play and people buy insurance b/c that’s considered the right thing to do.

2795

It seems to me, rather, that it hinges on the system absolutely refusing to treat anyone who has refused to buy into the system.

If doctors and hospitals still end up treating the uninsured, even though they are uninsured by choice, then this system is going to break down real fast.

2796

Hey, I am going to plead ignorance as well. I have tried to keep up along with following this thread, but I cannot process enough of the information to have a grasp on how it will effect on me. I understand it is not all about me and I do not mind doing my part to contribute to the greater good for those less fortunate than me.

You all may have addressed this, but as an example of the average, lower-middle class (whatever that means), I was hoping for some clarification.

That said. I am currently paying about $7,200 a year for my family coverage. I am well below making $100,000 per year and we are a one income household that lives pay check-to-pay check. Blue Cross Blue Shield of Alabama has a choke hold on insurance coverage in the state. However, I have had no problems with them. Our company’s Cancer rider saved me from tens of thousands of dollars worth of debt and possible bankruptcy. I feel lucky for that.

We have many health care facilities that serve Veterans and underprivileged and they are in notoriously sad shape. Doctors that serve there during residency do not want to go back. I think that is horrible and I know people that suffer greatly because of the lack of coverage. I want their care to be bolstered by this bill. I have a friend who has had to quit work due to back surgery at 54 and cannot apply for aid until 55. There is only a 4 month gap, but he may well lose his house before he can get the aid he needs.

BC/BS usually raises premiums around 8% a year here. This year they are not doing that. Instead they are raising co-pays for office visits, procedures and hospital stays. So as long as I do not need to use my insurance, it seems I will save money this year. That’s just super duper. [eye roll]

BC/BS “says” they performed an actuarial study that predicts and increase in premiums of up to $2,800 per year for those who currently have insurance. My educated guess is that there is little to no objectivity in that study, but if they produce a report that says it is by outside actuaries, some will view that as enough support to self-fulfill their own prediction.

  1. Is there anything in the bill that restricts insurance companies from raising premiums?

  2. How much truth and how much bull shit is there in that taxes will start being collected on the front end that will not really be used until 2014 when the “big stuff” is put in place?

  3. Will Congress be able to re-direct those funds elsewhere sort of like other Federal Aid funds have been in the past?

That is all. I tried to phrase those as unbiased questions. I hope they came across that way and not as any sort of knee-jerk, sky is falling crap.

2797

Tyjenks, the answer depends on whether or not you make less than $88,000 for a family of four.

According to the Washington Post, if you made $87,000 for a family of four:

Beginning in 2014, if you pay more than 9.5% of your income in premiums you will have the option to receive tax credits to help afford insurance premiums in the new exchanges as well as assistance with deductibles and co-payments. According to your income and family size, the tax credits will ensure you do not spend more than $8265 on premiums. Your maximum out-of-pocket costs for deductibles and co-payments would be capped at 30% of the total cost.

2798

Ty, the ability for the government to regulate increases was removed in the Senate bill. Depending on the November elections, that may come back as a separate bill.

2799

Yeah what you should do is TAX everyone progressively, and use that TAX to provide the government mandated insurance to everyone who is not not covered.

You fucking retards.

2800

Thanks very much. Have not been able to find that info.

I know up-thread it was stated that California monitors premium increases. I am relatively certain that Alabama has no such body for oversight.

It does not help that this has all occurred during the busiest time of my work and about all I have time for is headlines and brief interviews. None of which are anywhere close to in depth enough. This is probably one of my few long posts since December. (Many are thankful for that small blessing, one would imagine).

Really appreciate it. Its not like any of my Alabama Senators or Representatives can give me an honest answer. I read in the paper that even the Democratic members from our state voted against it.