OT: excess cost in US health care

Obama has been in office for some six years now, so a doubling in cost sinc e he took office is about 12% per year, of which a couple of percent will b e inflation.

What happened over eight years of Dubbya?

Since lawyers are over-represented on both side of US politics, the Republi cans will be being equally careful to avoid impairing their relative's inco me streams.

In reality malpractice insurance and the "defensive" medicine it inspires a re only part of the problem with the US health system. Atul Gawande's artic le - which provoked this thread - talks about wasteful over-testing and ove r-treatment but doesn't blame them on fear of malpractice cases, though it may be a convenient excuse.

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Bill Sloman, Sydney

Curious. Atul Gawande's article actually suggests that Obamacare enables a form of group practice that is less wasteful than most current approaches to organising medical care.

John Larkin won't have read it - The New Yorker is a bit more demanding than P G Wodehouse - and his comment has about as much relation to reality as his comments about anthropogenic global warming.

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Bill Sloman, Sydney

And on a two week development cycle. The next generation of product hasn't evolved very far, so the chance of an unfortunate mutation is consequently slight.

Thinking not being John Larkin's strong suit. But he's good at tinkering.

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Bill Sloman, Sydney

My family doctor has a web site, as does the hospital (,u cardiologist uses the hospital's). Who cares if they hired an IT guy to write the actual code (an outside company, actually).

I don't know what planet you live on but doctors are far from a monopoly on planet Earth. Of course your doctor isn't looking after YOUR INTERESTS ALONE. It probably never occured to you that his interests are pretty well aligned with yours. ...or you should find another doctor. Oh, I forgot, there is only one on your planet.

You lefties always look down your nose at others' decisions. You must have a Slowman-sized inferiority complex.

You *can* choose who gives you the vaccine. It's *not* an emergency.

So what? Are you saying that you don't need to be vaccinated? Idiot.

Good grief, how many times are you going to "educate" people? Haven't you figured out that some have no interest in an education? ...including teachers.

There you go, looking down that long nose again.

ges 42 through 53. It's title "Overkill: An avalanche of unnecessary medica l care is harming patients physically and financially. What can we do about it".

y line - "Waste is not just consuming a third of health-care spending: it's costing people's lives".

of US health care compared with French, German and Dutch health care.

a

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Atul Gawande notes in his article that "The passage of the Affordable Care Act, in 2010, created opportunities for physicians to practice this kind of dedicated care. The law allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an "a ccountable-care organization," and to receive up to sixty per cent of any s avings they produce. "

He attributes some of the improvement in McAllen, Texas - versus El Paso, T exas to the formation of two such groups in McAllen.

That does seem to be what the "accountable-care organizations" seem to be e xploiting.

e trenches who actually DO it every day--constantly scheming better ways to

James Arthur describes it, but doesn't recognise that Obamacare facilitates it.

That's not what Atul Gawande's article implies.

r

But James Arthur can't see it when it is happening, because it's happening because of a Demoncratic initiative, which can't possibly work, not having been approved by Bastiat.

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Bill Sloman, Sydney

Wow, Don that's long.

I think most of that boils down to,

We are rewarding Doctors for the wrong things.

It seems like something it would be easy to agree on.. but impossible in the current political climate. (As silly season approaches I imagine I'll pay more attention to sports...)

George H.

...even if they *aren't* trying to exploit the system!

If you put in mechanisms to try to control excesses, then you're seen as "interfering with the Market", "spying", "rationing", etc. (pick your emotional hot-button word/phrase).

Educating consumers always is the best approach -- not only to contain costs and drive "best practices" but, also, to improve their *own* care! Yet, try to put in "passive" mechanisms that track provider performance (hospitals, doctors, etc.) and you catch all sorts of resentment. Like "testing" in schools ("Oh, no! We can't possibly do that!!! Let's just wait 10 years and see which schools turn out doctors and which turn out used car salesmen...")

(sigh) The phones will be ringing off the hook with folks begging for money, attendance at fundraisers/rallies, pollsters, etc. (we seem to perpetually have some sort of "election/referendum", here, so someone is ALWAYS in your face about *something*...)

We're *much* better troubleshooters than doctors. They grab a couple shotguns and start blasting. They've got 30 minutes at a time. We get

24/7 feedback they don't. So, it makes sense we should do some of the work.

The ideal setup is a partnership--you get the data, then report.

Quite reasonable.

A doctor lit a fire some years back publishing a book on drug dosage, the nub being that most dosages are gross overkill, much lower doses nearly always work, and using lower doses nearly eliminates adverse effects.

Apparently they do something like, if a dose works for 80% of patients, and double works for 10% more, and double again works for almost everyone, they recommend a standard dose that's 4x what 80% of the population needs.

The doc recommended chopping your pills in half, then half again if still producing the desired effect (with a doctor's supervision). Saves money, side-effects, etc.

Yep. If we just made the prices public, and paid at least in part by the person purchasing--proportionally, according to cost--the whole thing would fix itself. Hundreds of millions of people making billions of choices every day would quickly, selectively adapt & optimize the system, same as for every other thing we buy.

That doesn't fix every single problem, but, if care cost half, almost everyone could afford their own, fewer people would need help, and helping those (fewer) people needing help would be much easier too.

Cheers, James

I've paid $1,380 recently for a crown, which seemed overly high, called another outfit, $930 for the same item from a recommended guy. Pretty good savings for just a little shopping. A fellow in another state said his dentist charges $550, he *thinks*.

The new 'thing' is a CNC mill that carves out your finished crown on the spot. Out the door fully fitted, no temps.

That's not inevitable at all. Obamacare has jacked costs up so radically, that they've waaay over-played their hand. It's well worth paying cash these days even with the tax hit, plus then your doctor works for you instead of for Obama's team.

Get lots of people doing that and the Obamacare people will feel like suckers, paying so much more for their cattle-call service.

I'm quite sure it's not intended. They absolutely did intend to wind up there, but they never, ever, ever meant for it to blow up on the launch pad. They're really just that stupid.

Cheers, James Arthur

Obamacare doesn't 'enable' Accountable Care Organizations--there was never anything preventing doctors from adopting that model, if they wanted.

Obamacare changes that. Obamacare forces doctors and hospitals to choose one of a few inflexible practice models Gruber dreamed up, overseen by "panels of unelected bureaucrats" (his words).

The ACO model pays according to fuzzy health outcomes gauged by a gang of gov't goons. There's a powerful financial incentive to cherry-pick healthy patients and turn away sick ones, which gets you the same pay with a lot less work & expense per patient. It kind of defeats the idea of what doctors are for though--taking care of sick people.

Cheers, James Arthur

Real single-provider systems are still composed of a substantial number of hospitals, most of them doing essentially the same procedures. Sensible sys tems concentrate the less frequently required procedures on a few specialis t hospitals, but you still end up with a number of independent teams of ope rators whose costs can be assessed independently.

That's exactly what happens in the Dutch system (and presumably in the Germ an and French systems) and under-performing tema get told to raise their ga me. The cardiac surgeons in Nijmegen were doing so badly about a decade ago that the whole team was disbanded and new surgeons hired. I don't know wha t the new teams costs looked like, but their survival rates were the best i n the Netherlands when they did my aortic valve.

Since the Germand and French systems cost about two thirds as much per head as the US system, internal competition does seem to work better than whate ver it is the the US has at the moment.

ld

ry

This is the free market delusion - every consumer making well-informed deci sions automatically leads to an optimal solution.

Sadly, consumers aren't well-informed and don't always make rational choice s. That's why real markets have depressions and recessions, and neo-Keynesi an economics works better than James Arthur's fairy tales.

ryone

(fewer) people needing help would be much easier too.

If you want care to cost half, copy the UK National Health System - that wo rks, now, while James Arthur's hypotheses are pie in the sky.

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Bill Sloman, Sydney

That is a good article. Thanks for the link. I am now recuperating from four-level cervical spine discectomy and fusion surgery, and I will probably have similar surgery on my lumbar spine later in the summer. But I have suffered from back problems for over 30 years, due to congenital spinal stenosis, and in the last 5 years the symptoms have gotten worse with no periods of relief as I had previously. I have exhausted conservative treatment options and my surgeon agrees with my own assessment that these procedures need to be done. They are risky, and he said a good outcome is for it not to get worse, but there is a good chance that it will improve things and allow me to be more active and engage in healthy activities such as long walks. Otherwise my lack of activity would probably cause other health problems.

It is amazing how many otherwise intelligent people embrace "conservatism" to the point of blind hatred for all things progressive, such as Obama and the ACA and any attempt to attain more equitable distribution of wealth. Such right-wing extremists seem to be very angry, possibly because their whole lives have been defined by materialism and greed and accumulation of monetary wealth. Thus they read only what they want to believe, and pick nits to find fault with articles such as this, if they even bother to read them with an open mind.

I re-established a friendship with someone I had lost touch with for about ten years, and when we talked on the phone for a couple of hours to catch up, I realized that the reason for our dissociation was likely because he was also a radical conservative, and he became profoundly angry and almost abusive when I tried to present some of my more progressive proposals and beliefs. I think it may be a fatal flaw in the mental make-up of those who move too far to the right, where it seems they get caught in the irresistible gravity of the black hole which is ultra-conservatism.

Thanks,

Paul

Sorry to hear of your plight -- it's a reminder that there are ALWAYS folks with worse problems than one may think *they* have!

At the risk of "prying", can I clarify that you have had "phantom" pain (poor choice of words... "your arms hurt even though there was no direct stimulus to them", etc.)?

A close friend has something "thoracic outlet " which, I understand, is a stenosis that impinges on the nerves around his collarbone (base of neck... maybe C5/6?). It results in a tingling, burning sensation traveling down his arms (left being worse than right). E.g., he is very reluctant to "look up" -- regardless of the incentive to do so!

My understanding is that the "solution" is to "roto-rooter" the applicable vertebrae to relieve the pressure on the nerve bundle(s). The biggest risk being damage to those same bundles (?)

I believe he, like you (?), also has similar damage to lumbar discs (though, in his case, most is the result of physical trama). And, the procedure/risks similar -- just different nerve bundles (e.g., some of the lumbar bundles could lead to incontinence, impotence, paralysis, etc.)

I think he has also had some "cauterization" of the nerves in the past -- a temporary measure. Another friend recently had much of her back treated similarly (scoliosis). She originally claimed "no difference" but has spent the past year largely pain free. Of course, nerves regrow -- albeit slowly -- so she expects the pain to return.

[I don't know what *causes* the constriction of the "outlets"; whether it is an inflammatory process, "hard water deposits", etc. But, as you claim, it is a progressive condition -- once started, it continually worsens (like hard water calcifications building up on a water faucet).] *If* this is correct, would you be willing to discuss your situation in more detail (email)? I'd like to be able to pass along any "first hand observations" that someone who's been *through* it has to offer. [Metal rods in your neck? We had a friend who'd broken her neck and ended up that way -- we'd jokingly comment that we would avoid being near her in Lightning Storms! :> ]

Regardless, best of luck for your recovery!

"Mine! Mine! Mine! Mine! Mine!"

Reminiscent of Smeagol...

Yet, not hesitate to take benefits from those programs to which they object so vehemently! :> Public schools, state universities, roads, environmental protections, labor laws, zoning regulations, etc.

[I recall being a third party in a discussion between a "left" and "right" neighbor. The "right" complaining about intrusive government, etc. The "left" replying: "You're absolutely right! Heck, I should be able to sell my house to a company that wants to erect a meat rendering plant on this site!" Suddenly, the "right" was very concerned about just how UNintrusive a government could potentially become! "Hey, why should I be prevented from selling my property just because YOU don't like who I choose to sell it to??"

Amusingly, this is the same "right" neighbor who complained when another of his neighbors was planning on painting their house *blue* (desert southwest... everyone seems to silently adopt a sand-brown color). "Hey, there's no LAW that says we can't paint it blue! Nothing in the CCR's -- besides, you aren't even a paying member of the HOA!"]

The same can be said of either "extreme". I can argue just as forcefully with my "right wing wackjob" friends as I can with my "socialist" friends. Neither ever see the folly of their opinions. Each tends to rationalize their beliefs in whatever view of "reality" they care to embrace. And, *freely* justify their inconsistencies -- as if entitled to them (sort of like a Catholic justifying their behavior by freely admitting "I'm a sinner!")

I have a very liberal friend who thinks healthcare should (effectively) be "free" -- and limitless (!!). Of course, his health care costs are astronomical -- he has no problem with *me* (with NO costs) carrying his "excess". Yet, when I suggest that the folks from The Wrong Side of the Tracks should be able to access his exclusive cardiologist (if they are willing to make the trip "across the tracks") -- after all, if it's FREE, it won't matter *which* provider you access, so why not avail yourself of The Best? -- he gets very protective of *his* provider: "No! They should access a provider on THEIR side of the tracks!"

("Ah, I see... 'I want YOU to pay for MINE but I don't want to share it -- even using the same rationale that I used to suggest it as the BEST solution'")

This is the drawback of adopting a label for yourself -- explicitly or implicitly. You lose choice and flexibility.

Odamma Care has increased the cost of drugs by a factor of (approximately) FIVE. So much for "affordable" care...

That is a good find Bill.

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John Devereux

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You were dissing Sloman's ragging, but when your own non-technical 
ragging is fed back to you as PKB, you dodge the issue by changing 
the subject in order to muddy the waters.

That's not the way Atul Gawande describes the group practice he was talking about. Granting that you fall some considerable way short of being an unbiased observer it's worth noting that the Affordable Care Act made it illegal for insurers to discriminate against patients because they have a pre-existing condition, so it seems unlikely that the Act would set up "powerful financial incentives to cherry-pick healthy patients".

Granting your capacity for selective vision, I can believe that you think that's the way the Act works, but it seems unlikely that you've got it right.

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Bill Sloman, Sydney

Care to explain the mechanism?

The Affordable Care Act extends health insurance cover, and restricts the patients that health insurance companies can reject.

If that can lead to a five-fold increase in the price of medical drugs, the trail of cause and effect has to be fairly indirect, and well worth spelling out.

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Bill Sloman, Sydney

And this is HUGE.

Largely stability, much less in premium rise and much less watering down of coverage. But best of all he understood what the real problem with health care is: Responsibility for self. So his administration did a few things right, for example instituting health savings accounts or HSA. Those can be used to cover co-pays, meds, dental, other med needs effectively with pre-tax money. If you take good care of your health, pay in diligently and end up not needing it all it'll become part of the retirement nest egg. Now that was smart.

Of course, Obama believes in the nanny state and partially dismantled this. For example, you cannot pay for all things medical with an HSA anymore. Meaning in effect some of people's assets became frozen after monies were paid in and could not be retrieved without a serious tax penalty. Oh, and he also doubled the tax penalties for early withdrawals. People felt betrayed and rightfully so but with Obama that is nothing new.

The problem is, much of this mess now seems beyond repair.

They have very little income from trial lawyers. They do from pharmaceutical and yes, that's a problem.

It is a huge part of it. It is also the reason why I am unable to obtain PL coverage for the US. Even Lloyds declined.

It is the excuse. It's easy to build your opinion from a few publications that suit your taste or political slant. It's very different to actually live here, work here (among other things in the medical field) and experience all this first hand. Only then can you know the real story.

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Regards, Joerg 

http://www.analogconsultants.com/