Comments on: Collectivists or Capitalists?

By: Savage Henry

Savage Henry — Wed, 12 Aug 2009 02:14:09 +0000

Tremble The Devil, you know I love you…but…you fundamentally misunderstand what (most) doctor’s relationship with money is.
Look at the opportunity cost of becoming a physician. They must do ridiculously well in college. They must jump through an unbelievable amount of hoops to get into medical school. In medical school, they spend two years studying their asses off, and a further two years drinking from the firehose of knowledge in their clinical rotations. During this time, they accumulate six figures of debt. Then the abuse really starts – 80 hour work weeks for about $40,000 per year. Even the very shortest residency is three years of this, and there are a few residencies that last 11 (eleven!!!) years. After that is the holy grail, the end of the tunnel – board certification. By this time, our young, bright eyed idealist is 30, with nothing in the bank and $200,000 of debt. After all that, a beginning Family Medicine doctor can expect to make $130,000 per year. In ten years of private practice, the doc can earn enough to be comfortable. I know a shitload of docs, and none of them are wealthy. They have nice houses and might drive nice cars, but in today’s system, the upper middle class is where 97% of docs end up.
If you rolled that salary back to 70k/year, I’m sure you’d get a few true believers, but I’ll bet many pre-meds would switch to Engineering or Business. Don’t fall into the trap of taking the docs dedication, sacrifice, brain power, and tremendous powers of delayed gratification for granted. More and more slots for generalist physicians go unfilled every year, lending truth to what I’m saying.
Regarding malpractice reform:
It it something that needs to happen, but it will not contribute significant savings to health care for a generation or two. The fear of lawsuits is too ingrained in the culture of medicine. If we implemented a sane malpractice system tomorrow, we’d need physicians to practice under it for 10 years before they allowed it to influence the way they practice. Then, those physicians would be able to train the next generation of physicians to practice in a more fiscally aware manner.
PL: That and the tort lawyers own the Democratic Party. Trust me. I’ve seen that firsthand. Bought and paid for years ago. Notice how gingerly Obama danced around the tort reform issue. He knows tort reform would be a plank of any real health care reform, but he’d be damned to say it out loud. The task of shoving that down the throat of the tort lawyers was going to have to be outsourced, spread around Congress and ultimately blamed on Republicans.
But it will come. In a future of fading margins, the “lottery” system that encourages thousands of shysters to fire up frivolous strike suits a year using a “one out of three settles for good money” formula to the detriment of hospitals, the court system and honest personal injury lawyers who find themselves maligned for the sins of their scumbag colleagues will need to be curbed.

By: Matt

Matt — Wed, 12 Aug 2009 01:25:44 +0000

I have been holding this in for several months, and I just have to say it:
If language is at least one of the factors that governs our reality, that is we make sense of phenomena by using language to describe it, and language is always evolving to meet the needs of a people in a moment then how the fuck am I supposed to take someone who identifies himself as a teabagger seriously (unless of course, this man were to be describing a sexual proclivity, in which case, God bless ‘em)? Sweet Jesus, it’s like a massive section of the population suddenly turned into Tobias Funke and decided to be “analrapists.” It’s not that I don’t see there point, or that I don’t want vigorous, informed debate. I desperately want those things. Do I want old, tenured conservatives and trustfund douchebags vigorously teabagging? Well, now that I say it aloud, I guess I would watch that if it was posted on the net. Sorry for the rant – I just wish people would give enough of a shit to take the time to craft a response to the prevailing winds if they have a disagreement and to really think about what they want and the best way to say it. It’s like James Carville said: do I think that transgendered transexual satan worshippers should be allowed to adopt children? Yes. Do I think that should be the centerpiece of the left’s response to what seems to be conservative tide, advocated and promoted in prime time? No.
PL: Tobias Funke… Damn that’s a great reference. When are they going to make the fucking movie of that series?
Language is limited, dude. Some people just can’t say what they mean. Exhibit A – the town hall screamers. Somewhere in there’s a point. The problem is, they lack the powers of articulation to cough it out coherently. So instead they get mad and replace what ought to be calm, concise analysis with volume and vitriol.

By: Dilbert

Dilbert — Tue, 11 Aug 2009 09:34:58 +0000

The article was fantastic and the commentary even better. I’m afraid I fall into that twenty-something group that is ignorant of much more than we are willing to admit. I think the main problem it has to do with is that finding reasonable places to get unbiased news is a bit difficult. The general news is usually filled with murders/kidnappings/rapists/etc. that we just couldn’t care less. At least at this point I have realized the ignorance is harmful and that I need to start caring again.
Also it was very refreshing to read from PL and EC about ideas that are very similar to my own but much better and more mind consuming. I tend to agree that the government continues to feed on a lot of people’s sense of entitlement that does nothing to help better our country. Like someone already said, once you give it to the public, you aren’t going to be able to take it away. It’s a disturbing trend I see among a lot of people my age who see no problem with giving more money to those who don’t care to work hard for it. It seems to me that our general disconnect with politics allows for a lot of people to believe that the money is free and it’s not going to hurt our bottom line.
I have a hard time with universal health care reform due to several issues. I believe that by forcing us into a system where everyone receives equal care, with no regard for the amount paid in, will only cause the level of quality that we currently have to go right into the dumps. ER lines are long now, and I completely expect them to become completely unbearable if everyone felt that they could go for whatever reason and not pay. Not to mention I have a hard time giving anything to anyone who hasn’t worked hard for it. That isn’t a popular way to look at things, but its the way I feel. I realize there are always exceptions, and I realize you will have to take account for those, but we need to stop giving everyone the we’re all equal routine. We’re not, and that’s what makes us great.
PL: The American Dream is you being left to succeed or fail on your own – nothing more, nothing less. The station you’re born at is either your advantage or disadvantage. Don’t like it? Find a way to rise above it. Hopefully you’ll succeed, but there’s also a good chance you’ll fail. If you do, it’s your fault. One way or another, you put yourself in the situation you’re in. There may have been other actors in the process, but ultimately, the fault, or credit for success, lies with you. Not just your hard work or lack thereof, but the decisions you made along the way.
Losers in the game bitch about how the system’s rigged against them. If you’re smart enough to spot how it’s being rigged, you’re smart enough to profit from the rigging. If not, shame on you.

By: Savage Henry

Savage Henry — Tue, 11 Aug 2009 03:20:02 +0000

I have one more thing I’d like to bring up.
People who say health care is a right are fundamentally misunderstanding what rights are. Rights are limitations on government power. You have the right to bear arms, the right to free speech, the right not to incriminate yourself. None of those things obligate anyone to give you anything.
I believe those of you who say health care is a right are misusing the term. You could call it an entitlement, or a moral obligation, or just a heck of a nice thing to do for a guy.
PL: Absolutely. And that’s the real nut of the debate here. We’ve been perverting the intent of the Constitution’s negative rights in favor of public policies that smooth out some of the meaner effects of Capitalism for years. There are sound arguments for that, but where does it go too far? I say this redistributive “reform” is too much.

By: TrembletheDevil

TrembletheDevil — Mon, 10 Aug 2009 18:08:04 +0000

Fine. Doctor’s should be wealthy, and it shouldn’t be like Germany where doctors make 70k, but at the very least they should be wealthy for being wealthy. Quite frankly, tort is most likely irrelevant because, as was noted in the article, there are extremely stringent tort laws in Texas and McAllen’s costs are still ridiculous. As for the other two issues, under a single payer the government could start doing things like rewarding the doctor for having healthy patients. The issue is that in Europe, there are giant entities worried about keeping the people healthy. In the US, there are doctors worried about making money.
Of course, Obama’s plan is just going to make things worse in this regard by opening up a larger government money bag right under doctors’ noses, so the costs will just go up and another panic will happen if this even passes. Oh well. Thought the guy would have a spine and focus on using his oratory to push the things he talked about rather than using it to set up his own re-election. Guess this is what I get for being optimistic. (Not that I’m mad, of course. If McCain won office we’d either be at war with Iran or wouldn’t have passed any stimulus at all.)
PL: It’s not Obama’s fault the plans he offered in the run up are not coming through as promised. The economic realities don’t allow what he promised and, to be honest, a lot of his followers expected some pretty exceptional stuff and were a bit deluded about how the process works. Politicians lie to get elected. He’s been more honest and pragmatic than most, but he had to do what he had to do to get elected. Our public wouldn’t elect an entirely honest candidate.

By: Savage Henry

Savage Henry — Mon, 10 Aug 2009 03:37:28 +0000

To: EC
There is no transparency in health care because the whole business is as clear as mud. It is more complicated than the Space Shuttle, and more mysterious than Stonehenge.
You asked a simple question that any provider of a good or service should be able to answer, namely “How much does this widget cost?” In health care, the answer is “Well…that depends.” Here is a hip pocket, wayyyyy oversimplified answer:
Everything in medicine is dependant on CPT and ICD-9 codes. There are codes for everyfuckingthing. There is a CPT code for a nurse wiping your ass, and ICD-9 codes for spacecraft accidents (Fact! Look up ICD-9 code E845.0 if you’re bored). Different insurers, groups within insurers, and government entitlement programs have decided they will pay varying amounts for the same codes. They also offer different “discounts” to their patients depending on what group of doctors the patient sees, and what circumstance the patient is in when the service is rendered. An emergent head CT (Cat Scan) for a patient with Medicare Advantage will be reimbursed at rate X. It’s Rate Y if the CT scanner is in an outpatient facility, and Blue Cross will pay Rate Z, but only if the patient goes to Hospital A. It’s like that for every single service you can get, from a tetanus shot to an emergent thoracotomy and an hour long resuscitation attempt including complete cranial-rectal inversion.
It is literally impossible for the doctor to know what the final cost for a procedure will net him. There is a whole profession dedicated to figuring out who to bill and what to collect – medical billers and coders. You can go to college and get an Associate’s Degree in this shit.
Who sets the prices, you ask? Near as I can figure it, the easiest answer is lobbyists and Uncle Sam. Different medical specialties have lobbyists, AARP has lobbyists, patient groups have lobbyists, etc. They all smoke pole at the Centers for Medicare and Medicaid (CMS). CMS factors in the lobbyist’s requests, then figures out how much money they have, then assigns a price. The private insurers take their cues from CMS, and typically offer a bit more for stuff. If the doc wants to participate in the program (i.e. accept an insurance or entitlement program) they have to accept the negotiated reimbursement. The price is not always coupled with how much skill, equipment, or expertise it takes to perform the task. The government has the hospitals by the balls, since most of the medical care (money made) involves old people, and old people have Medicare. It is impossible to operate a full service hospital without accepting Medicare – even Kaiser takes it, at least in my area. Thus, the government can set conditions for participating in the program, like the aforementioned EMTALA. Private insurance companies can set conditions like following JCHACO guidelines on so called “never events”, but their hand isn’t so heavy. If an insurance company gets to be a pain in the ass, the doc can (technically) opt out of their network. Hospitals can technically opt out of CMS, but in practice they’d go bankrupt.
Holy shit – I know that is over-simplified because I left out an alphabet soup of acronyms. Like PL said earlier, this goat rodeo is leading to many docs moving to concierge style practices. Basically, they negotiate with their patients for payment. Docs are free to charge what they’re worth, and the patients have some skin in the game.
As long as I’m oversimplifying, I’ll take a stab at what our problem is in health care: Middlemen. The doctors are dependant on the middlemen to get paid, and the patients are divorced from what their care actually costs. As a patient, why would you settle for Doctor Family Medicine when you can go see Dr. Super Endocrinologist for your problem? The only difference for you is a $20 vs $40 co-pay. Doctor FM has some disincentives for treating you, as well. Dr. FM might get paid around $50 from Medicare, $60 from BCBS, or $35 from Medicaid to see you. Since the reimbursement is so low, he’s got to burn through 30 patients a day to keep the lights on and the nurses paid. He doesn’t have time to research the latest treatment modalities and do the heavy thinking. Plus, if something goes wrong, he’ll be up on the witness stand answering all kinds of awkward questions like “Why didn’t you refer this patient to the appropriate specialist sooner?” The specialists are out there, worrying about how they’ll pay the mortgage on their specialty equipment, and the debt incurred in the years of extra training he needed.
Since the patient doesn’t care what things cost, they demand/expect the absolute gold standard of care, every time. If Little Billy fell on the playground and has a bruise on his noggin, Mom demands a head CT. After all, she heard what happened to Natasha Richardson! The lawyers are fuelling this, driving the so called Standard of Care asymptotically towards perfection. If the doc misses a one in a million diagnosis because he didn’t order a test, the lawyers ask more awkward questions. “Why didn’t you order a CT, doctor? Little Billy is a vegetable now, and you had a CT machine not one hundred feet from him the whole time he was in the ER!” Plus, the docs really don’t want Billy to be a veggie. Since no one is putting the brakes on, they order a $1,500 test (among others) to rule out that one-in-a-million brain bleed. Everybody’s happy, and your taxes/premiums go up and up and up.
Okay, you ask – why not get rid of fee-for-service? Pay everybody a salary. Level the field. This is a bad idea in the same way communism is a bad idea. What incentive do the docs have to see more patients? Why should they stay late? Why pick up the next chart? I work in a teaching hospital where the resident physicians are salaried ( a first year resident makes about $40,000/year, BTW). They have no real incentive to accept patients onto their service. The Internal Medicine guys are getting paid the same to take it easy carrying five patients or busting their ass with twenty. The surgery guys get paid the same if they do peri-operative care (before, during, and after the surgery) or they just consult/follow on a case (do the surgery and leave peri to someone else).
Let me tell you – sometimes it is a cast iron bitch to get a patient out of the ER and up to a floor. If you want a bigger example, go to a VA hospital. Try and get a test ordered after 4:30 pm. After you’re done tearing your hair out, you’ll recognize that fee-for-service has some benefits to the patient.
If PL doesn’t mind, I’ll blather on endlessly about this stuff.

By: Tom

Tom — Sun, 09 Aug 2009 23:16:02 +0000

Anyone who wants to understand health care needs to read this New Yorker article.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
It’s the strangest thing I’ve ever read. The difference between the Mayo Clinic and the most expensive health care area in the country doesn’t have to do with pre-existing health conditions, unhealthy living, tort issues, medicare versus private payment, or quality of care. The issue is that doctors are acting like rational economic actors, pushing procedures onto patients in order to make more money, milking money off of optional procedures, and focusing on the bottom line almost exclusively. Our health care system has become more capitalist over the past fifteen years, and it is killing us.
I just say we need to scrap the system and either start over or borrow from the Swiss or the British. We aren’t going to save a significant amount of money. The insurance companies have a 3% profit margin and the administrative costs aren’t going to save much. If the people who are actually running this circus debate want to fix health care overutilisation somehow needs to get into play.
Of course, I guess that’s the problem. The debate on health care isn’t a debate on health care, it’s a debate on the issues that the special interests regarding health care want to bring up. Everyone brings a bias into this debate, and because the issue is so huge it becomes a purely political matter. Nobody is interested in finding the problem. They already think they have the solution.
I remember you writing about how this forum is supposed to be a place to put in radical ideas that might save our lazy asses. I’m not sure whether you mean radical ideas or radical ideas (TM, copyright libertarian party), but to me that article’s ideas are radical, defensible, and not getting nearly enough attention.
PL: I read that article at the gym a while back and found it interesting, but hardly conclusive. It’s nowhere near the final answer to the question, Why have costs ballooned?
The piece is simplistic and fails to look at why docs act in the economic fashion it suggests (not surprising, as the NYer’s almost as slanted as VF in its approach to these issues). Docs have to make up for lost margins taken by insurers, their own liability insurers and the tort pirates.
Docs deserve to make a half million or more a year. I want the guy following my health to be fattened, wealthy and undeterred by business issues, so he concentrates on me. The cure is to cut out all of the actors eating away at the docs’ margins and take the money they’d receive and give to docs, so docs could make a fat living doing what they do, as opposed to having to play real estate developer, book keeper, accountant and regulatory lawyer on the side to maximize their take home.
Left leaners love to talk about how a society is measured by the way it treats its weakest. A society is better measured by how it treats its most important, most essential. I can’t think of any class of professional more important or essential than doctors, and we’ve been treating them like dogshit for the last two decades. They ought to strike and teach us all a lesson.

By: TrembleTheDevil

TrembleTheDevil — Sun, 09 Aug 2009 16:37:20 +0000

Fucking fantastic exchange, if this kind of thing actually made it onto CSPAN or Hardball we’d be a lot closer to fixing what’s wrong.
The only broad topic you guys didn’t really get into is the issue of wealth concentration, which has been getting a lot more acute over the past few yeas.
One way to capture it is by examining what portion of America’s total income the top 1% of earners receive. The share of that top 1% has nearly doubled since 1970, and it’s now the same size as the income earned by everyone in the bottom 40% of earners combined.
So the very few families who make up the top 1% of all earners have a combined income that matches the incomes of all the families in the bottom 40% of earners.
Looking at economic well-being another way, in terms of financial wealth or “stocks, bonds, real estate, businesses, and other financial instruments,” as of 1998 the top 1% of families controlled nearly half of that pie, with the top 20% controlling fully 93% of it. Meanwhile, the bottom 40% of families actually have negative financial wealth – their debts actually surpass their assets.
And this cavernous gap has only been widening, between 1998 and 2001 the net worth of families in the top 10% of America jumped 69%, significantly more than any other group. In the years leading up to that point, between 1988 and 1999, the difference in net worth between black families and white families grew by $16,000 and the gap in net financial assets grew by $20,000. By 2004 white families had an average net worth of $81,000, and black families an average net worth of just $8,000 – roughly a tenth the average white family’s.
Everything else being equal, wealth inarguable isn’t. I don’t know what kind of real social solutions there can be when the level of economic inequality is still growing. Addressing that would seem to overshadow pounding out the nitty-gritty of many more subtle issues, and although I couldn’t pull a concerete solution out of my ass right now – the first step is always to admit that there’s a problem.
#citations at http://www.tremblethedevil.com/my_weblog/vilest-deeds-like-poison-weeds.html – section vii#
PL: Economic inequality is reality. Capital begets capital and so it goes. Trying to fight it is like trying to fight social Darwinism. Sounds great, but it never works because at our base, we’re animals and — no losers, no winners.
Our inequities don’t accrue from flaws in our system. Technology speeds inequalities, the same way it did in the Industrial Revolution. The masters of the new age are taking the spoils for a time. It corrects a bit inevitably.

By: Evil Conservative

Evil Conservative — Sun, 09 Aug 2009 15:29:13 +0000

Well, first I want to thank everyone (especially PL for hosting) for a discussion that didn’t fly off the handle like so many political and emotional topics tend to do. It would be really great if there were forums and television programs that were like this. O’Reilly and Matthews each had something going in the 90’s, but they’ve both been intolerable for most of this decade.
Russert and Stephanopoulos are good, but one of them is dead and they almost exclusively talk to politicians and agenda-driven people. If anyone knows of any place in the media (from TV to the internet) where we can get the level of discussion here, please let me know. Thanks.
Savage Henry,
First post:
For points 1 & 3: where is all of the transparency we were promised so we could be educated health care consumers when the Health Savings Accounts came out 5 years ago? Where are the databases to tell us things like MRI’s are cheapest at Facility ABC, but most comfortable at Facility XYZ?
On point #2: One more thing here, there are suddenly tens of millions of new patients being covered for care they would not have sought out otherwise. It won’t be long before a percentage seek out lawyers to start suing the shortage of providers.
Second post:
Why are there not more Urgent Care centers? Would that help our nation’s health care costs?
I know some hospitals have already split their emergency room into two. One side of the ER has the critical patients rushed right in or have a shorter queue and the other side is a completely separate queue for less urgent care like waiting for X-rays. When I wanted to check my hand out after hurting it at a Slayer concert, I waited 5 hours in an ER on a Saturday night ($700 bill, I was responsible for $35 copay) instead of being able to go to a 24 hour, non-critical care facility down the road with a shorter wait that can handle X-rays, stitches, and other minor crap.
Jay,
A second thanks here to make a reasonable case from the country with one of the best universal health care systems.
PL: The media will rarely host debates like this. Better to have a zero sum game between a pair of advocates working 12th grade debate contest techniques out on each other.

By: Garibaldi

Garibaldi — Sun, 09 Aug 2009 15:04:38 +0000

Frankly – and maybe this is the secret Euro-weenie in me – I can’t possibly see how anyone can see health care as anything other than a basic human right. How anyone can approach the debate with the idea that it’s OK to leave millions of people without access to basic medical services is totally unfathomable. Perhaps it’s all the paste I’ve eaten.
PL: The debate isn’t whether everyone will receive some level of basic care where urgently needed, or some level of care for chronic conditions. There have been and will remain safety net programs providing that care to the un/underinsured, at state and fed levels. The debate is whether we should enhance that care to something approximating the care people with insurance receive, with the insured subsidizing the enhancement.