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Old 08-12-2009, 09:24 AM   #21
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I understand the rationale behind the comment, but I wouldn't say education is likely to be effective. Is there a significant population of Americans who don't already know that being fat, smoking, eating lots of "bad" fats, and being sedentary are unhealthy? People, for the most part, don't need to be educated, they already know what they need to know. Instead, they need to be motivated to make some changes in their lives if they are going to live longer.

When people trot out the numbers on US longevity and % of GDP devoted to medical care and use them to show that our health care system is more expensive and gets poorer results than the systems of Europe, Canada, or Botswana, these lifestyle choices are hardly ever even mentioned. If Europeans ate as much, weighed as much, or walked as little as Americans, I wonder what their health care costs would be. You can bet that a significant reason for the high medical costs in the US is the fact that, for cultural reasons, we don't take care of ourselves very well. Heck, maybe we've got an exceptionally efficient health care system and any other system would have higher costs given the McStresses we put on it! (I'm not being serious)
Just out of curiosity, what does everyone think of the "vice" or "sin" taxes that the government is using as motivators? For example, taxes keep getting raised on cigarettes as a way to get people to stop smoking. This would hopefully dislodge lung cancer as the #1 cause of death in the U.S. Today, Congress is considering taxing sugary sodas, a move that is vehemently being opposed by the beverage company lobbying groups.

On a general level, I have no problem with taxing destructive behavior as a disincentive for people to engage in it. The question is where do you draw the line, and do we want the Government to decide what is good for us? If taken to an extreme, steaks, burgers, hot dogs, wine/beer, etc... would be taxed out of existence.
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Old 08-12-2009, 09:59 AM   #22
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Quit checking An Taylor and Nieman Marcus. Take a look in TJMaxx and Walmart.
While I appreciate the suggestion, I think I will decline. It is true however, that the Super Walmart that I used to go to when I had a house drew heavily from the Carrier Base. Lots of fit young sailors of both sexes and foxy Asian wives. Likewise the nearest TJ Maxx in Bellevue sells lots of size 0 and 2. Their main shoppers are hot young and not so young but nevertheless hot Asian women and other assorted immigrants who like to be cute and stylish.

So I think maybe you get a truncated sample out there wherever you are. Come to the Land of the Sky Blue Waters and be happy.

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Old 08-12-2009, 11:27 AM   #23
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Let's face it, those in a position to REALLY change this thing don't REALLY give a flying hoot about those who are at the receiving end......they have theirs and the nail isn't stuck in their butt.

The answer is so simple a kindergarten child could answer it: Give the OPTION to ALL 310,000,000 Americans to have access to the SAME plan Congress has.......I didn't say give it free......pay what the lawmakers pay and lets move on to other pertinent pressing issues.............duh !

Why is everyone so concerned now about weather the insurers will go out of business or not or make a profit; they sure as hell don't give a damn about you.
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Old 08-12-2009, 11:58 AM   #24
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Why is everyone so concerned now about weather the insurers will go out of business or not or make a profit; they sure as hell don't give a damn about you.
I think the concern isn't for the insurance companies per se, but that it's possible that if reform is done the wrong way, there's a concern that what replaces insurance companies could be worse.

There's an old saying that goes, "Be careful what you ask for, because you might get it." That applies here. The fact that the current health care situation is a quagmire that needs to be changed doesn't mean that *any* change -- change for its own sake -- is a good idea. Assuming things can't be worse is a good way to make them worse if we're not careful about it.
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Old 08-12-2009, 12:20 PM   #25
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Again........Congress isn't going to have a plan for themselves that is beholden to the whems of the insurance carriers ; Big Brotha looks out for himself as he should.

Why doesn't everyone want what Congress has for itself? Are there any downsides?
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Old 08-12-2009, 12:34 PM   #26
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Why doesn't everyone want what Congress has for itself? Are there any downsides?
Cost would seem to be the obvious one. I have to believe that the plan Congress has would be too expensive to roll out to 300 million people.
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Old 08-12-2009, 12:48 PM   #27
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Do you believe our Congresspersons actually pay FULL retail price............due to economies of scale and an even larger group of hundreds of millions of enrollees, costs would come way down. Imagine all the surgeons, and other specialists who would salivate over this massive group of enrollees.............competition is good.
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Old 08-12-2009, 06:25 PM   #28
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I think I would have tackled this health care "reform" in a different manner. Seems like Obama is trying to do too much too quick. I think he should have taken Medicare as a project model for a "single payer system" if you will, and reform it by streamlining the record keeping, putting pressure on the drug companies to reduce costs, shorten the time to allow generics, making a really last ditch effort to trim staff, etc, etc. and then see where that leads in two or three years. Tell the people what you are doing and that by the end of your term a decision will be made whether to go forward with a universal plan. Hire a guy from BCBS or Aetna to spearhead this project. Of course, what the hell do I know? Not much in this regard. I do know this, as the saying goes, if your going to eat an elephant, you've got to do a bite at a time. This is one really big elephant.

Forgot to add one thing: instead of spending trillions of dollars at the start of this, I would have taken $25B(?) and bought a policy for everyone that had no insurance or guaranteed their coverage. That way everyone would have some insurance of some kind like Medicade.
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Old 08-12-2009, 06:43 PM   #29
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I think the dems know they will not hold the majority the hold now after the 2010 elections. This is not a comment on their policies one way or the other, just a fact of life for a mid term election. I think they thought with their outright control of both houses and the white house, the thought they could ram this through, and they still may. That is why there was such a since of urgency. I honestly believe it had to be pushed through before the people realised what was in it. That did'nt work, and now they are looking at a new game plan to see how much they can shove through.

I find it interesting the AARP is such a supporter. Well I did, until someone pointed out AARP was a huge in the health insurance business with huge investments with seniors. If you can curtail the cost of health care in the last year of life it means billions to their bottom line.
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Old 08-12-2009, 06:45 PM   #30
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Let's face it, those in a position to REALLY change this thing don't REALLY give a flying hoot about those who are at the receiving end......they have theirs and the nail isn't stuck in their butt.

The answer is so simple a kindergarten child could answer it: Give the OPTION to ALL 310,000,000 Americans to have access to the SAME plan Congress has.......I didn't say give it free......pay what the lawmakers pay and lets move on to other pertinent pressing issues.............duh !

Why is everyone so concerned now about weather the insurers will go out of business or not or make a profit; they sure as hell don't give a damn about you.
A number of legislators on both sides of the aisle have proposed simply extending the Federal program nationally but it keeps getting shot down for a variety of reasons. But that concept is not that far from what the "exchanges" that are proposed in the House bill would be. Insurers would come in and offer plans that all comers could choose among. Much like the insurers come into OPM to offer plans under the Federal health insurance program. It is certainly not a panacea - the Federal plans are not cheap by any means. And nothing about it drives down cost. The "Public Option" is supposed to set up a government run non-profit insurer to introduce more competition into the exchanges -- but that concept is getting hit so hard as a Government camel nose under the tent that it seems to be dead on arrival.
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Old 08-12-2009, 07:10 PM   #31
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I don't often comment on threads like these, however, there is so much misunderstanding about how health insurance carriers operate and their relationship with the government (state and federal), that I'd like to set some facts out.

1. Insurance carriers will go out of business if the government manages a health plan. No they wont. Today, the insurance carriers sell Medicare Advantage plans against Traditional Medicare (managed by the government), and they are still in business. The government would prefer beneficiaries buy Medicare Advantage so the government doesn't have to foot the liability for end of life illnesses (except for organ transplants).

However, every state's department of insurance stands to lose filing fees, operating costs, and tax base, when/if individuals move to the government plan -- not to mention control over the benefit language, auditing operations, and the general political nonsense that goes with it.

2. AARP is huge in the healthcare business. Actually, AARP is huge in selling licensing rights to its name in return for promoting products. They don't own the insurance plans they sell, other insurance companies do. What they own is huge mailing lists that are worth a lot of $ to companies who want to market to seniors. When approached to sell the list, they are happy to collaborate as long as they are adequately compensated.

3. The Federal Employee plan (what Congress and the President get) is too expensive for $300 million people. Actually, it's not. That said, however, one needs to understand that the Government negotiates a specific rate with about 40 insurance carriers who agree to administer the benefits for the rate specified (with/without any profit). The Plan is a single payer plan. The insurance carriers that administer the benefits, draw on the Office of Personnel Management to pay the claims. Like Traditional Medicare, they get a fee for processing the claim/handling customer service. If they do a good job in meeting customer service and claims payment standards, they get a bonus which must be distributed to the employees involved in administrating the plan. Your tax dollars at work -- not many insurance carriers earn the bonus.

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This whole uproar over insurance carriers is a lot of misdirection. The problems many have had with insurance carriers are a symptom of a problem, they are not the problem. The source of our health insurance problems reside in how much it costs to provide high quality health care. Health Insurers don't determine how much it costs, they only negotiate with doctors and hospitals to pay a pre-determined fee for every service performed.

Fee for service is the problem. It's piece work. And as anyone who has worked where they are paid by the piece, the more you do, the more you earn. It is unfortunate that our legislators are choosing to continue the status quo, without making a meaningful change to the way healthcare is delivered and financed.

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Old 08-12-2009, 08:02 PM   #32
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I don't often comment on threads like these, however, there is so much misunderstanding about how health insurance carriers operate and their relationship with the government (state and federal), that I'd like to set some facts out.
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Thanks Rita. A very helpful and well informed post.

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Old 08-12-2009, 08:23 PM   #33
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Fee for service is the problem. It's piece work. And as anyone who has worked where they are paid by the piece, the more you do, the more you earn.
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Thanks for the insights.

A question - I agree that "piece work" can be a source of problems, but what is the alternative? Now, if I'm sick I go to my doctor and he/she fixes it (hopefully). Sure, there is a financial (and CYA) incentive to run extra tests, make me come back for a consult, put me on a med that requires me to come back every 6 months, etc. Lots of room for abuse, or maybe a somewhat innocent jacking up of charges, with the doc convincing himself it's "just to be sure", that's how everyone does it, etc.

But how else would docs get paid? Just be assigned X number of people and given a salary? That doesn't make me feel very certain that I'm going to get the attention I might need. What's the motivation for the doc?

I have no idea if one of those options is better/worse than the other overall, or if there are other options. I'm just trying to learn.

TIA if you can add anything to this - ERD50
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Old 08-12-2009, 08:37 PM   #34
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But how else would docs get paid? Just be assigned X number of people and given a salary? That doesn't make me feel very certain that I'm going to get the attention I might need. What's the motivation for the doc?

I have no idea if one of those options is better/worse than the other overall, or if there are other options. I'm just trying to learn.

TIA if you can add anything to this - ERD50
The entire HMO concept is based on capitation, as are military systems and the UK public system.

My ex belongs to an HMO and seems to get excellent care from their salaried doctors. A lot of doctors like what they do, not just the money.

Also surgeons in these systems get their time and skills used very efficiently; and they get enough specialized work to stay on top of their games.

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Old 08-12-2009, 08:51 PM   #35
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My HMO is preventative based, and definitely not fee for service. This means sometimes you have to fight a little if you want something they would prefer not to give you (ie. special tests, services). This can be a bit of a pain, but I've never not gotten what I wanted with a little effort. On the other hand, the preventative aspect of their service kicks @ss! They'll make so much more money if you stay healthy that it's fully in their best interest to convince you to take care of yourself and get regular checkups. I know some people don't like the services, but I've been with them for over 25 years and think they've done a pretty decent job. I hope whatever comes out of all this debate keeps an option like this available.
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Old 08-12-2009, 09:34 PM   #36
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1. Insurance carriers will go out of business if the government manages a health plan. No they wont. Today, the insurance carriers sell Medicare Advantage plans against Traditional Medicare (managed by the government), and they are still in business. The government would prefer beneficiaries buy Medicare Advantage so the government doesn't have to foot the liability for end of life illnesses (except for organ transplants).
Something doesn't jive here. In his town hall meeting in NH yesterday, Obama singled out the Medicare Advantage plans as being subsidized to the tune of about $200 billion, and said the removal of this subsidy would be a source of cost savings. Obama said the Medicare Advantage plans cost the government more than traditional Medicare. Could you elaborate on this point?
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Old 08-13-2009, 11:30 AM   #37
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Something doesn't jive here. In his town hall meeting in NH yesterday, Obama singled out the Medicare Advantage plans as being subsidized to the tune of about $200 billion, and said the removal of this subsidy would be a source of cost savings. Obama said the Medicare Advantage plans cost the government more than traditional Medicare. Could you elaborate on this point?
It's a bit of a miscommunication, but not exactly off. You'd have to look at the details on the Medicare site about how they compensate plans specifically. But:

Medicare turns over a substantial part of the Part B premium to the insurer, AND, the beneficiary pays a premium -- you know that part. The insurer bears the risk, that is if the cost of care exceeds the premiums, the insurer makes up the difference.

It should be noted, that the benefit design of Medicare Advantage plans are richer (i.e., more benefits provided) than Traditional Medicare.

It should also be noted that the benefit designs are dictated by the government with the insurer only able to control the premiums (competitive advantage), and certain freebies (i.e., health club membership discounts, hearing aid discounts, pharmacy discounts when the beneficiary hits the donut hole).

These freebies are generally the same discounts the insurer offers to their privately-funded members. In the case of pharmacy discounts, some insurers also offer these discounts to their Medicare Supplement members (who do not have ability to buy pharmacy coverage). So they aren't giving much away, but they are making access to health care more affordable -- a very big give, knowing what we know about the cost of health care. AND every carrier has a member web site with health information and other information that encourages taking better care of yourself.

So it costs the government more? I'm not sure I agree, the government hasn't made the effort to arrange for 'freebies,' for traditional medicare beneficiaries.


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Old 08-13-2009, 06:23 PM   #38
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I agree strongly with Rita. For example, medical providers are rewarded for hospitalized patients, not well patients, even if the hospitalized patient gets an infection in the hospital. Yet providers are not sufficiently rewarded for helping chronically ill people manage their illness better so that they avoid the hospital.

There are a number of options to move away from fee for service, One alternative to fee-for-service is nonprofit health care cooperatives, proposed by the senate finance committe, where, for example, a doctor can earn a salary, rather than be paid by procedures/treatments. There is evidence that they are able keep the focus on outcomes, rather than this or that treatment. For example, mail and phone consultations are used more often, which can be efficient, but are about impossible to bill under traditional insurance. Apparently the physicians also end up working better with hospitals and specialists, which eat up a lot of money. I think of my elderly MIL who had a fair amount of disjointed care, with too many specialists doing too many discordant things, and her ending up with too much treatment yet not the best treatment. For example, is a significant dental procedure appropriate when you are dying of cancer? No one to coordinate the care as no one was paid to do so.

I understand that Massachusetts is also looking at ways to get away from expensive fee for service. I have heard about discussions where providers would be paid a fixed amount per patient, adjusted for age, health and other factors, with incentives for keeping a patient healthy as possible and happy. Some kind of bundling of payments for being responsible for a patient seems to make some sense.

We also may be able to use government incentives and disincentives to help encourage healthy behavior. We also could insure that procedures that are important and evidence based are encouraged.

I am with SamClem that education may not do much and healthy living is in large part a motivation issue. That is a tough nut to crack.

What I worry about all of this is it is so tough to get anywhere because we don't have a system to reform. We have a disjointed mess, with too many different interests. To please all those interests but try to have some protections we end up with 1000 page bills. And people tire of it, get distrustful and worried. I have tired of it because the debates are not on issues that I am interested in or concerned about, but are debates about the contest itself, rumor, and small hot button issues. I am so sick of it that I could spit. I am concerned that everyone will tire of it and nothing will be accomplished.

Here is some interesting comments by a physician, in an HuffPo article. I should clearly state that I am not a fan of Huffington Post, especially their medical articles, but this guy has some sensible things to say. I have not vetted his claim about tort reform in California. http://www.huffingtonpost.com/dr-pau..._b_258388.html
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Old 08-14-2009, 11:54 AM   #39
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Why not take one issue, say portability and solve that. Nothing else just that. Structure a bill that allows portability. It should not have to be 1000 pages, should not have any other type of reform, just solve portability. Vote on it sign it and then ask what is the next thing that needs to be solved. Lets say it is cut cost through streamlining of medical records. Once more one bill on only one issue.

While this may take longer, if the bills were short and clear, without all the hidden agendas, I think most Americans would go along with it. Sooner or later you are going to get down to an issue that just does not have public support. As some one said before, 'how do you eat an elephant', well they seem to be trying to gag it down in one bite, and Martha may be right, they may not get anything.

I would not like to see the current plans pass. Not because I am opposed to reform, but because I don't trust any bill that is between 600 and 1000 pages to implement. I don't care if it is Republican or Democrat, there is too much hidden in the tortured language of these mega bills.
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Old 08-14-2009, 12:03 PM   #40
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We also may be able to use government incentives and disincentives to help encourage healthy behavior. We also could insure that procedures that are important and evidence based are encouraged.
I do not believe that this is the only thing stopping getting to healthier behavior.

On so many issues, there is a lot of distance between what is supposed to be healthy, and what various groups are pushing, and actual scientific proof that these are accurate. The recent debate on this board about heart healthy diets, fats, and carbohydrates, and Rich's input which I believe has strongly changed over the last year or so might be enough to convince us that public health consensus on some important topics would not necessarily align with science.

Did a typical 60 year old man 80 years ago suffer from not having the government tell him how to live? Let's not forget that study funding, the media and government health panels are not really medical science, they are highly political operations.

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