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Old 06-19-2009, 05:14 PM   #61
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Not exactly the same thing (but close), but as a woman who is 6' tall, I've never met anyone who didn't have something to say about my height, and have heard ... "how's the weather up there" more times than I can count.
By the way: When someone asks you that, the proper response is to spit on them and tell them it's raining.
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Old 06-19-2009, 05:18 PM   #62
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By the way: When someone asks you that, the proper response is to spit on them and tell them it's raining.
Excellent! I'll do that next time. Thanks
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Old 06-19-2009, 05:27 PM   #63
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Have you compared prescription drug prices? The U.S. is, to some degree, subsidizing the rest of the world for the R&D for new drugs.
I think this is a factor. I don't know if it's 1% or 5%. Either way, I think "health care reform" should include a provision that the US gov't isn't going to pay any more for prescription drugs than the average of other rich countries. There's no reason for us to pay for the whole world's pharma R&D.
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Old 06-20-2009, 08:45 AM   #64
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Things that make our US healthcare so expensive

lifestyle (obesity, smoking, drugs)
high cost and profit for intermediaries (insurance)
excessive profit for some product and service providers
administrative burden (millions of microplans)
high charges for specialized services
forced use of expensive specialized facilities for routine medical needs (emergency room)
multiple regulations around the country
punitive legal awards
diagnostic overuse (expensive tests even for routine matters)
treatment overuse (especially end of life)
excessive unproductive labor vs technology
All true, plus significantly/ironically, excessive usage by those who have health care insurance. My MegaCorp provides great benefits and most of our employees overuse them because they pay so little of the cost. Just a few examples:
  • going to the ER when not necessary with colds, flu, nosebleed, etc.
  • purely elective procedures that we should not pay for, but are covered.
  • some of them also stay out on medical leave (much) longer than necessary because most doctors ask them when they want to return to work instead of recommending when - I have seen it over and over again.
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Old 06-20-2009, 09:38 AM   #65
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Things that make our US healthcare so expensive

lifestyle (obesity, smoking, drugs)
high cost and profit for intermediaries (insurance)
excessive profit for some product and service providers
administrative burden (millions of microplans)
high charges for specialized services
forced use of expensive specialized facilities for routine medical needs (emergency room)
multiple regulations around the country
punitive legal awards
diagnostic overuse (expensive tests even for routine matters)
treatment overuse (especially end of life)
excessive unproductive labor vs technology

Our current dysfunctional approach to healthcare has evolved over decades, driven by a unique combination of medical and financial motivations. It is both quite good and quite bad.

“Comprehensive healthcare reform” is going to take a long time. The ideological and financial interests today are well entrenched. Starting with high upfront costs in the midst of a recession – well, it’s a hard sell. The version they’re considering now makes more sense.
Excellent list.

Googling a little, I get a number of references for end-of-life care as 10-12% of total medical spending. This includes all the expenses in the last 12 months of life, regardless of the prognosis at the time (i.e. some of this money was spent on people who the doctor expected would live). If you focus on just Medicare, it's more like 25%. I don't have a comparable number for other countries.

I think that "treatment overuse" is prevelant in other situations. Someone with a painful knee and insurance in the US can get an MRI within a day or two. Maybe the MRI doesn't turn up anything, the knee would have recovered on its own, and the MRI was "wasted". I've had physical therapy for injuries a couple times in the last two years. In both cases, the first session was the most important as I found out what was wrong and got some DIY exercises. Later sessions probably helped it heal sooner, but they cost fellow-insured's a chunk of money.

I think the reason we don't attack most of the things on the list is that most Americans don't know how much they are spending for medical care. Some say "The insurance company pays for it". Others think a little further and say "My employer pays for it", and never stop to think that this is money that could/should have been in their paycheck. For others "The gov't pays for it". We do a great job of hiding the cost of gov't programs. Most workers can see the Medicare tax of 1.45% of wages. They don't realize that's only 25% of the total taxpayer subsidy of Medicare. So the actual cost 4 times what they see.

If I were doing healthcare reform, I'd push to make sure that people can see the full cost of medical care. Make sure that all Federal funding comes from a single, visible, named tax. Eliminate the tax deduction for employer-paid health insurance. I think the only way we will make good decisions on medical expenses is if people can see both sides of the cost/benefit decision.
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Old 06-20-2009, 11:18 AM   #66
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Excellent list.

Googling a little, I get a number of references for end-of-life care as 10-12% of total medical spending. This includes all the expenses in the last 12 months of life, regardless of the prognosis at the time (i.e. some of this money was spent on people who the doctor expected would live). If you focus on just Medicare, it's more like 25%. I don't have a comparable number for other countries.

I think that "treatment overuse" is prevelant in other situations. Someone with a painful knee and insurance in the US can get an MRI within a day or two. Maybe the MRI doesn't turn up anything, the knee would have recovered on its own, and the MRI was "wasted". I've had physical therapy for injuries a couple times in the last two years. In both cases, the first session was the most important as I found out what was wrong and got some DIY exercises. Later sessions probably helped it heal sooner, but they cost fellow-insured's a chunk of money.

I think the reason we don't attack most of the things on the list is that most Americans don't know how much they are spending for medical care. Some say "The insurance company pays for it". Others think a little further and say "My employer pays for it", and never stop to think that this is money that could/should have been in their paycheck. For others "The gov't pays for it". We do a great job of hiding the cost of gov't programs. Most workers can see the Medicare tax of 1.45% of wages. They don't realize that's only 25% of the total taxpayer subsidy of Medicare. So the actual cost 4 times what they see.

If I were doing healthcare reform, I'd push to make sure that people can see the full cost of medical care. Make sure that all Federal funding comes from a single, visible, named tax. Eliminate the tax deduction for employer-paid health insurance. I think the only way we will make good decisions on medical expenses is if people can see both sides of the cost/benefit decision.

I'd take it a step further. You need to see it and be on the hook for part of it. I'd say on a good day less then 25% of the patients I see in the ED need to be seen and evaluated there. Without a financial penalty to be there they will continue to over utilize the ED.

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Old 06-20-2009, 01:28 PM   #67
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I have always thought that one of the problems i.e. things that cost more, is the number of Hospitals that compete for business. Now normally you would think competition would lower cost, but with every hospital 'having' to have all the modern equipment and them under using it, cost goes up. I guess a way to look at it is there is some very expensive equipment siting idle and not making money.
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How health reform may help ... or hurt
Old 06-20-2009, 02:33 PM   #68
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How health reform may help ... or hurt

Something I haven't seen addressed here is how the plans taking shape in Washington will effect those of us without subsidized health insurance who plan to retire early, or who have already retired early. The various plans seem to include a few basic principals 1) Mandates that every individual buy insurance 2) No "pre-existing condition" exclusions 3) subsidies for lower income families.

At least one consequence of these provisions seems pretty obvious to me. Areas of the country where individual health insurance is currently cheap may become much more expensive because of the requirement to insure "pre-existing conditions". Some of that increase may be offset by the individual mandate, but my guess is we'll see rates in cheap areas rise and rates in expensive areas fall.

Anyone currently enjoying individual coverage that only costs a couple grand a year may want to start budgeting for more. Maybe a lot more.
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Old 06-20-2009, 03:27 PM   #69
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I have always thought that one of the problems i.e. things that cost more, is the number of Hospitals that compete for business. Now normally you would think competition would lower cost, but with every hospital 'having' to have all the modern equipment and them under using it, cost goes up. I guess a way to look at it is there is some very expensive equipment siting idle and not making money.
There has been a lot of competition at the hospital level, and many have closed. As an example many HMO's have realized that it is cheaper to contract with a hospital for hospital based care then try to run their own hospital. One facility where I work has contracts with 2 local HMO's, one of which just closed its last hospital several months ago. They pit the local hospitals against each other to get the cheapest contract they can. They pay nothing for ED care for patients we admit and a minimal flat rate for those we discharge - regardless of how many tests, time etc they take. The hospital hopes to make up for this by getting paid for the hospital based care that is provided for the admitted patients.

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Old 06-20-2009, 04:05 PM   #70
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Something I haven't seen addressed here is how the plans taking shape in Washington will effect those of us without subsidized health insurance who plan to retire early, or who have already retired early. The various plans seem to include a few basic principals 1) Mandates that every individual buy insurance 2) No "pre-existing condition" exclusions 3) subsidies for lower income families.
Subsidies for lower income families might work out really well for many FIRE'd folks that have low incomes. But if asset testing (similar to medicaid) is brought into the subsidy equation, we are screwed. Maybe they will exclude retirement accounts like IRAs and 401ks from the calculations. And there could be an age above which assets won't count against you (like 55) where you are essentially getting income tested medicare at 55 instead of 65.

Any idea if the income limit of $66,000 for a family of 4 results in a family receiving the full subsidy or is the subsidy likely to be phased out as income increases up to $66,000 for a family of 4?
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Old 06-20-2009, 04:06 PM   #71
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Something I've never understood is why all these megacorps who allegedly are so crippled by employee health insurance, haven't made use of their lobbyists over the years to change to promote a government system and get themselves out of the health insurance business.
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Old 06-20-2009, 04:28 PM   #72
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At least one consequence of these provisions seems pretty obvious to me. Areas of the country where individual health insurance is currently cheap may become much more expensive because of the requirement to insure "pre-existing conditions". Some of that increase may be offset by the individual mandate, but my guess is we'll see rates in cheap areas rise and rates in expensive areas fall.
I would think rates will be kept in check by requiring young, healthy people to buy insurance.
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Old 06-20-2009, 04:45 PM   #73
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Interesting article in the WSJ this morning A Doctor’s View of Obama’s Healthcare Plans - WSJ.com

There are many similarities between our national financial problems and health care. Both are the result of years - or decades - of living with bad habits, being aware and well forewarned of the consequences, but continuing to live with excess until being forced to take action. They represent the two biggest financial challenges to the US in over a generation. We will all pay for the solution, and those that did not abuse, lived within their mean and followed the most healthful lifestyles will pay nonetheless even thought they incur no "personal cost" - in the financial mess or health care.

At some point, those of us that live careful and thoughtful lives should be able to reap the benefit and not continually pay for the disregard and thoughtlessness of others. Doesn't look like it's going to happen anytime soon, though.
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Old 06-20-2009, 07:57 PM   #74
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Interesting article. I think this is the key section:

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.... health care costs in McAllen are twice that of comparable cities while health outcomes are no different. The reasons are complex but probably because good physicians are ordering lots of tests, calling in lots of consultants, making good use of the equipment they own and the imaging centers they might have a stake in (and yes, they think they can be objective in ordering an MRI or CAT scan that sends the patient to their own facility); it has to do with hospitals competing with each other for the kinds of patients with conditions that are reimbursed well, and wooing patients, wooing high-volume physicians (some of whom are invited to invest in the hospital) to make full use of their PET scan, their gamma knife, their robotic-surgery facility, their cancer center, their birthing center. That was Atul Gawande’s conclusion, and I would concur.

But I’d like to officially let McAllen off the hook and say that having practiced in five states, including 15 years in the great state of Texas, we are all complicit in practicing just that kind of medicine if you look hard enough and if you looked at us individually. Conflicts of interest are rife; they are almost the rule. So is the ability to wear blinders so we are (mostly) oblivious to our conflict.
Here's another good section:
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Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc).. But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)—I don’t see the savings there
Even without conflicts of interest, doctors will want to "do what's right for the patient in front of me, regardless of the cost". And patients will always want to have any procedure/test/drug the doctor recommends. We need to embed a cost-conciousness into the system some way, because there are so many different ways for costs to expand.
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Old 06-20-2009, 07:59 PM   #75
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I'd take it a step further. You need to see it and be on the hook for part of it. I'd say on a good day less then 25% of the patients I see in the ED need to be seen and evaluated there. Without a financial penalty to be there they will continue to over utilize the ED.

DD
Thanks for the addition.
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Old 06-20-2009, 08:40 PM   #76
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Well this may change the debate: Poll finds wide support for healthcare changes | Reuters

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Seventy-two percent of those questioned said they backed a government-administered insurance plan similar to Medicare for those under 65 that would compete for customers with the private sector. Twenty percent said they were opposed.
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Old 06-20-2009, 08:47 PM   #77
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Results weren't exactly black and white:
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The poll found that people were uneasy about heightened government involvement in the healthcare sector, with 77 percent saying they were very or somewhat satisfied with the quality of their own care.
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Old 06-20-2009, 11:44 PM   #78
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Results weren't exactly black and white:
This is an interesting, recurring finding in studies on health care that has been present for decades. Individuals will state that the system is broken and needs to be fixed, but are satisfied with their own care and do not want you to mess with their plan. That is why I think Obama and others clearly state they will not get rid of existing plans as part of the restructuring as that would not be palatable.

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Old 06-21-2009, 09:26 AM   #79
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Eliminating these negative lifestyle choices would be the greatest factor in reducing health costs
Safeway Health Plan Reduces Company Costs, Promotes Preventive Health

Safeway CEO Steve Burd, who has spoken about the plan to more than 300 executives during the past three months, said, "What is the revelation Safeway had two years ago that completely transformed our thinking? That 50 [%] to 60% of all health care costs are driven by behavior," adding, "If you design a health care plan that rewards good behavior, you will drive costs down."
A system like that really would be fantastic. Rewarding the behavior of the insured.
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Old 06-21-2009, 12:22 PM   #80
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Subsidies for lower income families might work out really well for many FIRE'd folks that have low incomes.
The problem they seem to be running into is the cost of the subsidies. Stay tuned.
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