Health Care Thread

Nope it's a room, in this case on the 10th floor of one of the main buildings which is also their transplant recovery floor. So it's not an ER nook-type room but rather completely intermixed with the admitted gen pop if you were. They talk about it explicitly in the "welcome" guide that was waiting for me in the room. Quite fascinating from a health policy standpoint

I'll be able to post a pre- and post-obamacare cost of the same surgery here in a few weeks.

Eh, could or could not be relevant. Had "identical" surgeries in the past at the same hospital months apart that cost differently with nothing changing.

Surgery isn't like home repair, they're under no obligation to stick to an estimate if anything changes.

McQueen_sl said:

I'll be able to post a pre- and post-obamacare cost of the same surgery here in a few weeks.

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I would not be shocked by a favorable result for Obamacare in this area - is not standardization of cost of medical procedures a big part of ACA? (regionally)

<Rambling begins>
In terms of actual healthcare, other than questions of who will bear the expense, a problem for ACA is what's going to happen with primary care doctors. Seeing a specialist in the US is much easier than in the UK or Canada with good insurance - much shorter wait on average. Where the US falls far behind is access to primary care doctors. One reason is that we already have a shortage of primary care doctors, and the supply is only shrinking further.

Primary Care Doctor Shortage - How Does the Health Care Law Address It - AARP

the United States is short about 16,000 primary care doctors ... Why the shortage? It starts with huge medical school debts and ends with a doctor who is often overworked and underpaid. While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt - $250,000 is not unusual - which prompts them to switch to a more lucrative specialty.

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Sounds like a problem - how does ACA address it? Let's take Medicare for example. One might think allowing primary care doctors to charge more, thus enticing more to enter this field, thus increasing the supply of service providers, thus reducing the cost of services (through competition) to a market determined equilibrium point, thus providing the same quality service as before to as many as possible, would be the way to go. *note - I in no way imply this was how things worked pre-ACA for Medicare.

No, instead we will use wise central planners, the champions of efficiency. Our central planners, being very wise, foresee all obstacles and are never taken by surprise by external events which might impact ability to meet artificial target growth rate. Just look at how well another of our central planners, the Great Bernanke, predicted and pre-empted the 07-08 financial crisis. /s
Independent Payment Advisory Board - Wikipedia, the free encyclopedia

which has the explicit task of achieving specified savings in Medicare without affecting coverage or quality. ...will determine in particular years the projected per capita growth rate for Medicare for a multi-year period ending in the second year thereafter (the "implementation year"). If the projection exceeds a target growth rate, IPAB must develop a proposal to reduce Medicare spending in the implementation year by a specified amount.

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In other words, primary care doctors aren't going to be seeing pay increases for Medicare patients (10% bonus through 2015 meaningless long term). We're going to see rationing of a diminishing supply. The supply will diminish because there will be no increased incentive for people to become primary care doctors on the basis of pay(already low), and the supply will be rationed because that's how central planners determine who gets which services.

Note: Providing money to train additional primary care physicians is not necessarily an incentive for someone to actually practice primary care - doctors can and do respecialize:

AARP:'Only one in five graduating internal medicine residents plans to go into primary care medicine, the Journal of the American Medical Association reports."

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What will the rationing look like? Same as always - substitute a lower quality service to mask reduced access. Back to AARP article:

The ACA authorizes money to increase the primary care workforce by training more doctors, nurses, nurse-practitioners and physician assistants. ... The law expands the number of patients seen at community health centers in areas with too few doctors and increases the number of staffers who work in the centers. It also expands nurse-managed clinics at nursing schools where nurses in training see patients who live in the area.

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MD's are expensive. We'd save a lot of money by replacing responding to the primary care physician problem by supplying physician assistants, for example, to fill in the gaps. Save even more with nurse practitioners. This is the future of healthcare under ACA - fill in doctor shortages with less qualified professionals, save a lot of money. I'm sure IPAB and policians will have plenty of bullshit to spew about how this is not a reduction in quality of care. Whatever the bullshit, I know who I want reviewing for interactions between my prescription drugs.
*I know PA's practice under the supervision of MD. This is not the same quality of service as directly being seen by the MD.

You do realize that the AMA is the source of your "problem" you mention, right?

There's a limit to how many doctors of a given specialty are ALLOWED TO ENTER PRACTICE every single year by the AMA as a non-government entity (although given permission to by the government indirectly since their approval is required to practice). There has yet to be a year I've heard of where there hasn't been at least a few general practice MD's turned down because the quota was full - in over 20 years of being aware of the issue. Maybe even 30 years, I think I learned of it after passing on the idea of trying to be a MD not before though, was roughly around the same time however.

Additionally on the IPAB - you do realize that the previous non-government board that handled such things was recommending to stagnate the Medicare rates because due to value adjustments on the USD that was what the math apparently dictated, right? And that the IPAB basically stated that there should be a larger increase than others suggested. [And note, private insurance is scheduled to go up 5% in the same timeframe on average, with many private insurers REDUCING payment amount this year...] The only reason it's temporary is because in theory the math should go back to working properly and not showing that the Medicare rate should decline again, but to keep things appealing to MDs right now they're actually increasing it in defiance of the math used for decades that the previous non-government board used religiously.

Again, you start going off on something without even understanding the fundamentals on what you're babbling on about. Things like the AMA limits are inexcusable to miss when alleging a problem of "making the field more appealing" - you could literally increase the appeal a hundredfold and without the AMA adjusting how many they allow to enter practice, we'd see zero new practicing doctors. Your solution is awesome.

Vaclav_sl said:

(1)You do realize that the AMA is the source of your "problem" you mention, right?
There's a limit to how many doctors of a given specialty are ALLOWED TO ENTER PRACTICE every single year by the AMA as a non-government entity (although given permission to by the government indirectly since their approval is required to practice).

(2)Additionally on the IPAB - you do realize that the previous non-government board that handled such things was recommending to stagnate the Medicare rates ...

(3)Again, you start going off on something without even understanding the fundamentals on what you're babbling on about. Things like the AMA limits are inexcusable to miss when alleging a problem of "making the field more appealing" - you could literally increase the appeal a hundredfold and without the AMA adjusting how many they allow to enter practice, we'd see zero new practicing doctors. Your solution is awesome.

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(1) Then not addressing this problem is a failure of the ACA. The AMA may be making the decision, but the government is enabling them. At best this is a team fail between gov't and AMA - both are liable.

(2) I made no claims about pre-ACA Medicare. So the new central planners are a little better than the old ones? Fine. All criticism of central planning is still valid. If you don't agree, go read a history book, focus on 20th century, then come back. (hint: count the number of starved Soviets and Chinese vs Americans, or hell, even French).

(3) I proposed applying free market principles rather than central planning. You tell me there's another regulation barrier, backed by the gov't, preventing that from working. Awesome, knock that one down too. Fixed for you?

Let's take Medicare for example. One might think allowing primary care doctors to charge moreand telling the AMA to fuck off with the bullshit limit during a shortage, thus enticing more to enter this field, thus increasing the supply of service providers, thus reducing the cost of services (through competition) to a market determined equilibrium point, thus providing the same quality service as before to as many as possible, would be the way to go.

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Finally, I know this isn't ever going to happen. Medicare has always been a centrally planned service. It's built that way, and at this point it's not viable to totally replace it with something else while maintaining smooth access to services for those on Medicare.

I was merely pointing out the deficiencies of central planning to date, and how we can expect the deficiencies to continue under ACA. If you add information concerning AMA limits, my points are still valid. So pointing out I missed AMA limits does not refute me. The new information allows me to enhance my argument, in fact.

**edit:
On reflection I noticed you blamed the AMA alone for the primary care physician shortage. This is not correct. Again:

While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt - $250,000 is not unusual - which prompts them to switch to a more lucrative specialty.

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Doctors switch speciality during medical school and also after, as they find the pay for running primary care practice not up to their expectations. AMA limits appear to be part of the source problem, and pay another. ACA does not effectively address either.

1) You remove the AMA's controls and you remove qualifications for doctors as well - giving them the oversight to make sure doctors are qualified also gives them the controls over supply. Because either they'll just flatly say they're allowing X amount or logistically they can only do hands-on testing for X number - either way, it's a choice between doctors that meet a standard or going back to Snake Oil.

2) And Free Markets have their issues as well - see "The Jungle" amongst others... And the proper term isn't "Central Planning" for most of the things you've talked about it's "CentralIZED planning" the minor change in letters changes it from a pure form into a hybrid, and the hybrid forms are much better. (i.e. Medicare is a CENTRALIZED planning program - it's got aspects of free market and central planning in it, with none dwarfing the other) There's ranges on the scale that could be debated, but implying the needle should be more than 80% either direction is pure Randian lunacy that's not based upon reality. [Even the Wild West was more "central planning" that current medicine for Christ's sake... town's richer folks paid for one or two doctors to oversee the town for free besides any parts costs that the patients footed themselves for almost every single town in the frontier - and most of the large coastal cities were the same, although with more benefactors and doctors]

3) Redundant no need to answer.

Final assertion on debt: Being raised amongst doctors my entire life (with my odd condition and an RN mother that brought me to work rather than daycare'ing me, I get to know tons quite well) the primary problem isn't the pay to being a GP, it's the pay to being a GP if you want to be your own boss - the overhead on running an office is pretty horrendous and medical schools never really cover the MBA stuff that an office really needs to understand regarding how to cost their services and proper number of people to employ, etc. GPs working in a joint practice where they've got no connection to the actual practice management are actually beating out a number of specialties when it comes to how much they earn per year because they don't have to worry about the overhead of the office, plenty however get sunk because they have the debt from med school then take on another $250-500k to open up a practice, then start trying to make headway. [And note the lower figure there was one quoting to me getting USED medical devices and the like, $500k was the average he was quoting for new equipment]

MDs that tone down the ego and realize that they need to start off working for someone else for a while, then can branch out on their own once their debts are taken care of can and do flourish as GPs. That way its more like a standard work track rather than trying to be a start up business, which everyone knows a damn high portion of new businesses fail within the first two years. [80% I think was the figure pre-recession, no?]

Additionally, when it comes to "supply issues being something the ACA didn't address" - it was never intended to - it was never even in the scope of the bill. (Additionally as far as I'm aware the problems you're talking about aren't actually solvable by legislation - Congress is only allowed to provide formula to the advisory board for pay rates, they can't make any final decision on payment even if they defunded it budgetarily they're required to pay the overflow out of "provisional" parts of the budget; and for the AMA the charter for the DHHS includes that the AMA dictates who is able to practice or not - so would require dismantling a huge department and then rebuilding it to remove the AMA from the equation to my knowledge)

But please, do keep the political naivete up - it's amusing to me to see a "know it all" that knows so little - but then runs off and makes wide assertions with their complete abject ignorance - and then even when they acknowledge a data point, they still think the same solution works... just pounding their head into the wall melding their world view around the answer they decided upon before even understanding the breadth of the problem.

fanaskin_sl said:

The AMA doesn't directly restrict the amount of doctors entering the system, the AMA acts as a lobbying group, congress restricts the amount by controlling the funding of residencies.

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Absolutely incorrect. The AMA puts forth the criteria for receiving a medical license and they only put out X licenses a year, and Congress doesn't fund any residencies except those directly connected to DHHS, the VA or NIH.

From wiki: Profession and Monopoly, a book published in 1975, is critical of the AMA for limiting the supply of physicians and inflating the cost of medical care in the United States. The book claims that physician supply is kept low by the AMA to ensure high pay for practicing physicians. It states that in the United States the number, curriculum, and size of medical schools are restricted by state licensing boards controlled by representatives of state medical societies associated with the AMA. The book is also critical of the ethical rules adopted by the AMA which restrict advertisement and other types of competition between professionals. It points out that advertising and bargaining can result in expulsion from the AMA and legal revocation of licenses. Restrictions against advertising that is not false or deceptive were dropped from the AMA Code of Medical Ethics in 1980 (AMA Ethical Policy E-5.02). The book also states that before 1912 the AMA included uniform fees for specific medical procedures in its official code of ethics. The AMA's influence on hospital regulation was also criticized in the book.

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They've recently started changing their tune, but have yet to relax anything themselves.

Vaclav_sl said:

You do realize.....bla bla bla, right?

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You do realize that you use this stupid phrase about 300 times more than a normal person, right? Possibly used once every 10 posts.

Why? Does it make you feel 'correct' when you ask a question in that manner?

Hint: It actually makes you sound like a dolt.

I use identical phrasing often, I'm not very creative verbally. There's a reason had lopsided SATs back in the day. 800 Math/320 Verbal.

It's certainly a weakness of mine and I'm sure rather annoying. He'll, sometimes I'll catch myself repeating phrasing 3 or 4 times in a single post.

Fana: I see your disconnect, I was speaking on the TRAINERS cost, I was unaware of where residents get their check from and it does appear the Fed is involved there. So they do have at least one pursestring they're involved with that I missed.

Although come to think of it all Medicare costs go through the IPAB and it's AMA run predecessor. And the IPAB still takes AMA advice. So they're still tenuously tied.

Qhue_sl said:

So one day into my new Obamacare plan (virtually identical to my Romneycare) and my gallbladder decided to declare a revolution against the proliteriate.

Will be interesting to see what the final bill ends up being considered the ER visit, hospital stay etc.

Noticed something interesting in the paperwork this morning when I was lucid enough to read it: observation status at a hospital. Not admitted so billed as outpatient, but taking up a room+nurse+scan+IV+drugs etc.

I think they will be changing my status to admitted now that I've been here awhile, but still a fascinating loophole for both the hospital system and insurance companies and another reason the out-of-pocket max may be a critical value even if you think you have all bases covered.

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Demand they remove the observation status from your paperwork.
This is story about medicare but it might pertain to you.
How to Avoid the Two Words that Cost Thousands in Medicare Bills - NBC News

They upgraded me to admitted as soon as I inquired about it and mumbled something about that being standard practice after 24 hours... and yet they have literature they hand out that says otherwise so I am more than a little suspicious. The practitioners themselves seemed genuinely confused about it when I mentioned it, either that or they are quite good actors.

I had something along the lines of that story you linked in the back of my head as soon as I read the sheet of paper (which due to incapacitating pain etc was more than 48 hours into my hospital stay)

Vaclav_sl said:

Additionally as far as I'm aware the problems you're talking about aren't actually solvable by legislation -Congress is only allowed to provide formula to the advisory board for pay rates, they can't make any final decision on payment...

But please, do keep the political naivete up -

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I mean, holy shit. You seriously see nothing wrong with this? What matters self-determination through representative democracy, when we can appoint a board of wise experts to make some of the most important governing decisions. If it appears the wise experts are at fault for creating a shortage of GP's? Well, nothing to be done, not even by the elected representatives of the people, from whom all political power rightly derives. /s

You accused me of not knowing basic civics? You call me naive? Then, you defend this? Wow.

Vaclav_sl said:

1) You remove the AMA's controls and you remove qualifications for doctors as well - giving them the oversight to make sure doctors are qualified also gives them the controls over supply.
2) And Free Markets have their issues as well

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1) No. They can do additional testing or they can fuck off and make way for someone who will. In the situation as you describe, the AMA is nothing but a part of the central planning scheme that led to a shortage. Oh, but wait - the guys who run the AMA like being in charge, and have friends in DHHS? That's too bad, I guess we should just bend over and take it in the ass rather than try to make a change.

I'm not surprised you take this view. After all, you're the guy who said the American middle class had it too good for too long, as if it's a righteous correction that we be brought down to relative poverty and dependence on the state, rather than the result of mismanagement, corruption, and flawed ideology destroying the legacy of the most productive people in history (post-war American middle class).

2) Yes, there likely needs to be some regulatory body, but a relatively weak one, so that we can tell them to fuck off once they inevitably succumb to regulatory capture. You indicate that the AMA has interests so entrenched at the DHHS that dismantling the system they have created that led us to a shortage of GP's is too difficult. This is not an argument for what you think it is.

Re GP's: Let's hear more about how it's an ego trip for highly trained professionals to want to be their own boss. Here, have some more rope.

One the initial part, you do understand the reason is because Congress can't be expected to understand the minutiae to the topic fully, right?

It would be awesome if they were supermen that knew everything on every topic, but they don't - thus why it's delegated.

They'd just be throwing darts otherwise and hoping for an accurate figure.

(Note: They can technically override things if they want FYI it's just only ever been politically viable once, when they boosted the minimums on the formulae to not go negative. Who's that? Because they follow expert opinion since only a fraction know anything of medicine)

That is why you're naive, the Congress you want can never exist because Congress us made of humans not omniscient superbeings.

Re: GPs - Name another degree you expect to be your own boss on day 1 out of school unless you're wealthy already. (where the debt argument is already moot)
Lawyer? No. MBA? No. Politics? Nope. Engineering? Nope. Architecture? Nope.

You might accelerate to being your own boss quickly in those fields if you're talented but day 1 is a drastic rarity.

Might address the rest later heading to wife's surgeon appt so no more time for other points.