Fundamental Differences

[Embar Angylwrath]

Admit that the statement that "the only people who are happy with the system are the bureaucrats who get paid to run it" was either a lie or ignorance on your part.

Asking anyone for an admission in a discussion is proof-positive that the person asking for the admission is on weak footing... or his name is Mahmoud Ahmadinejad.

[Lurker]

Riiiight, Embar. Asking someone to admit to basic facts is a sign of weak footing.

My pointing out your ignorance about the public option and your refusal to admit your were wrong wasn't a sign of your ignorance, it was a sign of my weak argument! That makes sense.

[Lurker]

If you want to hear something from someone who actually knows a little, instead of just spouting Party Line crap about Health Care Reform, take a look at this interview with the CEO of the Mayo Clinic.

And nice trick there, linking to an interview and then following it with your own opinions about Medicare.

In the interview you linked, Dr. Denis Cortese does criticize the fee-for-service flavor of Medicare and says the public option shouldn't mirror that. But he's supportive of having a public option, he likes what he sees in the House and Senate bills, and he thinks Obama is focusing on the correct questions. He has high praise for Peter Orszag and Zeke Emanuel with the Obama Administration, saying "They know what really needs to be done." He's not in favor of eliminating Medicare. He thinks IMAC is a great tool that will help lower costs. He understands that the CBO can't score the long term savings reform will bring. He also mentions the Commonwealth Fund which is pro-reform and pro-public option.

In other words, the person you point to as "someone who actually knows" about health reform agrees with the Obama Administration and disagrees with you.

/golfclap

[Eidolon Faer]

Actually, he criticizes the "Price controls" aspect of Medicare as much or more than the fee-for-service aspect.

Basically, Medicare is like Wal-Mart on steroids. They tell you what the price for a given disease is, regardless of individual patient considerations or the real cost of the treatment. And because they're so big, you have to think really hard about not playing along. The fact that so many physicians are opting out of Medicare should tell you something.

It's called Diagnostic-Related Groups. And it results in all kinds of unintended consequences.

And I've been saying I would not be opposed to a public option IF said public option was a good one. If it sucks, I oppose it. And given our political system's penchant for having the attention span of a ferret on crystal meth and the morals of...well...politicians, I am inclined to examine the details of such a plan very closely before agreeing to support it. Hopefully our nation's mortgage-defaulters will have learned the same lesson.

AS Dr. Cortese says, there are good and bad aspects to all of the proposals currently on the table. The devil will be in the details.

[Eidolon Faer]

And actually the HMO model is probably the closest to what I would have in mind. Just for the record. I don't presume to speak for Dr. Cortese in this matter.

[Alluveal]

WTF. Eidolon!

(huge hugs)

I miss pestering you. Hope life is well.

[Lurker]

Actually, he criticizes the "Price controls" aspect of Medicare as much or more than the fee-for-service aspect.

No. He doesn't say price controls are the problem. He says price controls combined with fee-for-service is the problem.

The public option in the plan depends on what we mean by the public option.

If we mean a Medicare-type option that has price controls, and it`s fee-for-service, that will be a catastrophe. We`ve seen it already in Medicare, it`s the largest public insurance company. It`s been up and running for many years. It`s had price controls under its control for -- since 1983.

And with price controls, what are we seeing? People just do more. The rate of growth of spending has still gone up.

What he doesn't mention is that the rate of growth of spending in Medicare hasn't gone up as much as for private insurance. I agree it's a problem, but it's not limited to Medicare and, as Cortese says, we should address it with IMAC or something similar. Which is exactly what's being proposed.

Cortese said he'd like a TRICARE like plan for the public option. That would work.

P.S. Embar is too big a pussy to admit when he's wrong. Any chance you'll admit you were wrong about satisfaction levels in Medicare?

[Partha]

This is the same Mayo Clinic that was pushing the Shona Holmes story...

[Eidolon Faer]

Satisfaction levels among doctors or among patients?

The section of the interview you talked about alludes to the following (very common) scenario:

Patient comes in with ailment X. Patient needs a simple test. Medicare pays less than what it costs to run the test.

Doctor either:

(1) Loses money, leaves medical practice, and starts a landscaping business

(2) Refuses to let the patient in the front door

(3) Orders the simple test...then orders 10 more tests the patient doesn't really need (but that the doctor can half-assedly justify if anyone calls shenanigans), for which Medicare DOES pay more than cost, just to stay in business.

And yes. This happens quite frequently.

[Ddrak]

Medicare pays less than what it costs to run the test.

They should just bill the patient for the difference (warning them before they run the test, obviously).

Dd

[Lurker]

And yet Medicare has slower cost growth than private insurance. It seems odd to condemn Medicare when it's performing better than private insurance in the area you are complaining about. Makes it look ideological instead of fact based.

Yes, there are problems that need to be fixed, but billing for unneeded tests is not something unique to Medicare. It's a problem throughout the healthcare system. That's why Obama has been speaking out against fee-for-service for several months now and saying that we must change the incentives for how care is given. IMAC or something like it will be part of the final reform package and that will directly address the problems you have with Medicare.

We know that if the Mayo Clinic or Geisinger are doing things smarter for less money that there should be ways to incentivize other health systems, applying these models. So that's one set of major reforms. And what we think is the most powerful lever to achieve those reforms is this MedPAC idea that we provided a very detailed proposal to Congress on.

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

Satisfaction levels among doctors or among patients?

Patients. The people receiving the care.

[Eidolon Faer]

Medicare pays less than what it costs to run the test.

They should just bill the patient for the difference (warning them before they run the test, obviously).

That's actually illegal. If you accept Medicare's lowball payment, you can't bill the patient for the same procedure.


And, btw, this also causes private insurance to get more expensive. Let me explain how:

(1) Remember that "half-assed justification" part of the previous scenario? Well, usually it involves "Needing to rule out one-in-a-million freak issues". Hospital administrators, ever conscious of the bottom line, then create things called "test panels" that order the whole expensive battery of crap whenever a patient comes in with a given common problem. This lets them do the same thing to private insurance companies in order to further spread the costs from Medicare patients. It also gives more cover to the doctor because he can say "I was just following institutional protocol" when wasting all this money.

(2) If you pad the test menu for a medicare patient, you have to gouge a private insurance patient in the same way for another reason: lawyers. It's called "Defensive Medicine." Basically, if you treat two patients differently for the same condition, both of them will probably try to sue you.


And the beautiful thing? Medicare doesn't care, because people like Lurker will rave about how great Medicare is all day long, despite the widespread havoc they're causing.

[Eidolon Faer]

Oh, and Lurker...

If Medicare didn't have privately-insured patients to leech off from, trust me, their patients AND their cost numbers would be a lot less upbeat. Creating a Universal Health Care system will effectively kick that crutch out from under Medicare.

I already talked about the stuff Mayo is doing to achieve cost efficiencies (referring to the quote block you posted) in a previous post -- it's not one big thing, it's "a lot of little weird things" like having that nurse call you to follow up on your care. It's a lot of stuff that costs money UP FRONT and saves money later on. And bureaucrats HATE stuff like that because they can chop it, get a bonus for cost savings this year, and move on to another job before the shit hits the fan. The Government incents short-sighted planning.

I don't know exactly what the other institution you mentioned is doing, since I don't get their employee newsletters.

[Lurker]

Eidolon,
Can you list which tests Medicare reimburses less than cost for? I think you're arguing by anecdote. You also haven't explained why the supposed cause of all this havoc is still performing better than private insurance.

And the beautiful thing? Medicare doesn't care, because people like Lurker will rave about how great Medicare is all day long, despite the widespread havoc they're causing.

Hardly. Problems can be solved without histrionic demonizing of the system. Saying 'OMG Medicare is the worst most evil thing ever and everyone hates it!' isn't helpful or honest. The reform proposals in the House and Senate include eliminating waste in Medicare resulting in hundreds of billions in savings, and as Dr. Cortese said in the interview you linked, IMAC would go a long way to fixing the specific problem you complain about.

[Eidolon Faer]

I don't work in Billing. And the per-test cost varies by institution and by test. If you are a small hospital, it may cost $25 to run a Liver Enzyme panel (as a hypothetical example) because you only do 10 of them a day and you have a certain kind of equipment. If you are a huge one, you may do thousands of them a day, and this lets you drive the per-patient cost down to say $5 each (Chemical Engineers call this 'Economics of Scale'). So if Medicare pays $6 per test, most places will lose money hand over fist but a few will be OK. Let's just hope you can drive 8 hours to one of those big regional hospitals when you turn yellow from acute hepatitis.

So I'm not going to bother to play along with your "Oh yeah, well name me three..." argument. It's weak and you know it.


And I'm disappointed in you for another reason. I just DID explain why Medicare is performing better in costs than private insurance. Let me spell it out, in case your coffee hasn't kicked in yet.

(1) Medicare lowballing causes EVERY patient to have more tests ordered.

(2) Private Insurers can't just change the law, they have to pay what the test actually costs the hospital. Their costs are disproportionately effected.

(3) Medicare just further lowers reimbursement rates if they feel the pinch, causing a self-reinforcing feedback loop which further punishes private insurance.

[Eidolon Faer]

And Lurker...

"OMG Medicare is the worst most evil thing ever and everyone hates it!"

Honestly...a strawman THAT obvious? I feel embarrassed for you.

Medicare started out as a good idea. I never said it did not. I am in agreement with Obama, Dr. Cortese, and pretty-much every sane person on the planet that everyone *should* have some form of health insurance.

I have also explained how bureaucrats (both Government and non-Government) are incented to be short-sighted douchebags who could (and in this case, have) fuck up a wet dream.

[Lurker]

I don't think "OMG Medicare is the worst most evil thing ever and everyone hates it!" was an unfair characterization of what you actually said... "It's horrifyingly expensive, and has twisted the nation's health care system around itself in a number of unintended ways. The only people who are happy with the system are the bureaucrats who get paid to run it."

(3) Medicare just further lowers reimbursement rates if they feel the pinch, causing a self-reinforcing feedback loop which further punishes private insurance.

Can you show the last time Medicare lowered their reimbursement rates under the scenario you describe?

====

In any case, we agree that the reimbursement structures need to be fixed and that fee-for-service needs to go away. Problems that are addressed by solutions advocated by Obama that are being incorporated into the House and Senate bills.

[Eidolon Faer]

As I said, I don't work in billing.

I *do* know that at the professional conferences I attended this spring, one of the speakers was a Department-Head level Physician from another institution, and during his presentation he complained about Medicare chopping reimbursement rates for a particular lipid panel assay routinely given to measure Cholesterol for those with other cardiac risk factors (ie. typical Medicare patients). The shift was from ~$35 to ~$6. And he seemed to have the attitude that this was an all-too-familiar pattern.

There are TENS OF THOUSANDS of tests listed in Medicare's reimbursement schedule. Tell me, which people in the Chicago Phone Book have moved in the last 6 months?

[Eidolon Faer]

And yes. We agree that Fee-For-Service *and* short-sighted bureaucratic penny-pinching are an extremely bad combination.

I'm simply of the opinion that a government-run solution is, in the long run, unlikely to be beneficial. Competition, in which institutions where short-sighted bureaucrats run amok are allowed to die, are more likely to retain the sorts of efficiencies Dr. Cortese talks about. Even at Mayo, there's a constant battle with retards who don't "get it."

And another issue that *needs* to be addressed is irresponsibility on the PATIENT end of things. The cost to society of a *single* crack baby, over the course of its' life, is astronomical.

Like I said at the beginning of all this. It's an *extremely* complex issue. We need to set the system up so that *everyone* is incented and helped to do the right thing, whether it's the bigwig setting policy, the doctor ordering tests, or the patient making day-to-day decisions. It's not even the "Health Czar" appointed next year...it's the retard that gets slapped into the post 15 years from now that worries me.

[Fallakin Kuvari]

Its the fact that we have these "Czar" posts that don't answer to anyone but the President that worries me.