From a doctor's perspective, is it better to repeal or keep healthcare reform

[surftheiop]

Uh. Duh.

It's kind of why we're even having a discussion. You don't get bonus points for extraneous and obvious information. Hell it's not even low hanging fruit.

To point out that competing schools of thought actually doesn't address the current argument though. I do, however, see what you did there.

You would be surprised how many RP/Mises folks can't admit that there are other philosophically consistent stances to have. I guess your one of the high functioning ones

I completely understand how intellectually appealing libertarian thought is, I was libertarian all through high-school and most of college, donated to RP's campaigns, won over tons of classmates, etc. But over time I sort of realized I gravitated so strongly towards libertarian ideas mostly because its such an easy position to debate from. You start with some axiom about the right to control your body (which most people agree on), and quickly you will establish the right to property and then you (all importantly!) bring the hammer by showing taxes are theft/immoral.

But now I tend to think that just because something is easy logically, it doesn't really have any bearing on whether it is true in the real world. But I do still really like a lot of libertarian thought, especially related to foreign policy.

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[scarshapedstar]

There is no right to free healthcare. No right can exist which infringes upon the rights of other individuals, which a right to healthcare does. It means confiscation of other citizens' property to pay for that healthcare or infringement upon the healthcare providers' liberty by forcing unpaid labor and expenses upon them. You may say you think it is right to provide universal healthcare, but it is not a right.

If a Chinese tank is rolling down your street, do you feel that you have a right to military defense? I mean, the Army or Air Force guys were perfectly happy sitting around at base. When you make them come blow up a tank, just because you're too lazy to do it yourself, you're forcing unpaid labor on them.

If you're going to ignore "promote the general welfare" you might as well ignore "provide for the common defense" as well. There is nothing so special about healthcare that prevents it from being lumped in with everything else the government uncontroversially provides. You may disagree with it but it's dishonest to argue that one service is violent coercive confiscatory fascism and the other is not.

And who said the doctors don't get paid by the government? This may come as a surprise, but there was a time when Medicare was the greatest cash cow ever. Although they weren't paid in gold ingots, so you could argue that they were never really reimbursed.

 

[jdh71]

It's also not an argument for their existence. Just because I feel my right to free delicious ice cream has been violated does not mean there exists a fundamental or intrinsic right to free delicious ice cream.

True. Which isn't the argument being made for their existence, though.

 

[SpecterGT260]

way too much to read.... but here are my thoughts on some needed healthcare changes or considerations:

1 - do not expand mid-level provider privileges. I'm sorry, but primary care doesnt need to be flooded with people who are driven more by protocols and flow charts than by a workable understanding of the body and disease.

2- along the same lines - monetary incentives for primary care. no more of this tuition reimbursement and loan perk crap for rural med. I mean increase payouts for primary care and decrease specialty payout. I say this with hesitation because I do not like primary care. I'm thinking something peds surg at the moment. However if i want to stop thinking of myself and think long term for a fix for medicine, shift the competition from ROADS to primary. There is just no real reason for derm to gross at the high end of specialty with a cush schedule and an ample supply of skin creams. I know there is more to it, but many derms in private are basically running glorified salons and making bank while getting reimbursed from insurance.

3- cut elective treatments and procedures from insurance. If someone wants to have something done because it is an irritant they can pony up. Maybe we can include some legislation for an applicaiton process for elective procedures..... (im thinking deviated septums here for example). something you don't need but may increase quality of life. we dont want to restrict practice or deny patients something they need, but we also don't need insurance and the government paying for crap just to make you comfortable.

4 - remove all insurance coverage for common sense things. Yoga is now covered under insurance. SERIOUSLY??? from this perspective EVERYTHING is health related. Why isnt health insurance paying your auto premium and tune ups? a healthy car decreases injury risk... on that note, remove ALL insurance coverage for things that are not evidence supported and get the FDA to grow a pair and deny approval for things that are harmless but not effective. some insurance covers chiropractor visits, and since we are already ok with yoga why not massage? what is the copay for a happy ending? we have too many people sticking their fingers into healthcare and getting financial support for things they dont really need. no wonder our system is taxed. Honestly government insurance should only reimburse primary care and suggested screening (the cheaper for the pt the better here), Rx's, and specialist visits/procedures. If you have private insurance that wants to cover a weekly visit to the herbachironaturohomeoprocto-chakratologist then that is none of my business.

5- cap and revamp malpractice. negligence and quack docs suck, trust me I know. But every department in every hospital out here is spending too much time and energy covering their own asses or building up a buffer in the inevitability of a lawsuit. The ER doc i used to shadow hated ordering all of the tests for mundane things, but if he didnt a coincidental (and obviously unconnected to a physician) medical issue could hang both him and his hospital out to dry. this is unreasonable. IMO malpractice lawsuits should be capped at 100k (open to negotiation on that one) and the offending hospital is bound to provide free healthcare to the person related to the accident. If we wanna get all scientific lets look at functional losses - paralysis, dismemberment, ect, and compare rates in the general pop to within the hospital. Nick the brachial plexus of an award winning pianist? Sorry bro, you already had a 1 in XXX chance of losing that hand just going to work today, I'm not about to bankrupt this hospital so that you can continue playing pianoman trying to get into the pants of the nearest socialite. That said, up the ante for true malpractice - if you dun goofed... that happens. If a board of peers can prove that you were doing something really inappropriate, say unbundling your charges, over perscribing with a kickback, or getting knife happy to pay off a yacht... then you lose your license... this is already the case. The civil aspect of this takes into account the emotional factor of severity. Human error is random, not experimental, therefore it is constant. The likelihood that a surgeon will cut farther than he wanted to into a panniculus for a tummy tuck is similar to the likelihood that he will cut too far into a brain for a tumor (i'm ignoring other safety measures... but the point is a medical goof that ended up with little effect is no more or less serious than a medical goof that results in severe symptoms since both occur randomly with otherwise competent physicians).

if we can bring down the cost of everything by taking some of the fear of god out of hospitals of lawsuits I bet the current popcultural fanaticism about healthcare will wane a little

 

[jdh71]

You would be surprised how many RP/Mises folks can't admit that there are other philosophically consistent stances to have. I guess your one of the high functioning ones

I completely understand how intellectually appealing libertarian thought is, I was libertarian all through high-school and most of college, donated to RP's campaigns, won over tons of classmates, etc. But over time I sort of realized I gravitated so strongly towards libertarian ideas mostly because its such an easy position to debate from. You start with some axiom about the right to control your body (which most people agree on), and quickly you will establish the right to property and then you (all importantly!) bring the hammer by showing taxes are theft/immoral.

But now I tend to think that just because something is easy logically, it doesn't really have any bearing on whether it is true in the real world. But I do still really like a lot of libertarian thought, especially related to foreign policy.

Well, it's probably not good too make too many assumptions.

My sort of general position is one I think is interesting and nuanced. I'm actually more of an anarchist than anything, but have swung back around for practical purposes to a minarchist position at baseline that allows for negotiation and compromise . . . because we have to come up with a plan for dealing with the *****s, the criminal, and poor (and don't think because I've put them together there, I think they are the same thing [some are though]).

As such I see the natural rights argument as the most natural and correct, but I do appreciate there do exist other ethical systems, most of which, like Bentham's utilitarianism, tend to try and maximize the group over the individual, which I find repugnant. Yes, we are a social animal, but we are individuals who live in groups. We're not hives, or prides, or a congress . . . it's different. Protection of the individual is paramount in my mind, and negotiating a social contract from those limitations placed on government are important to me. The problem with the opposite is that it simply leaves no room for lines in the sand. If government, tomorrow, decided that baby rape was ok, then by the logic posited by my opponents in this discussion, it would be. I take the position that baby rape is ALWAYS wrong no matter what you, anyone else, or any government has to say about it. Lines in the sand.

 

[SpecterGT260]

If a Chinese tank is rolling down your street, do you feel that you have a right to military defense? I mean, the Army or Air Force guys were perfectly happy sitting around at base. When you make them come blow up a tank, just because you're too lazy to do it yourself, you're forcing unpaid labor on them.

If you're going to ignore "promote the general welfare" you might as well ignore "provide for the common defense" as well. There is nothing so special about healthcare that prevents it from being lumped in with everything else the government uncontroversially provides. You may disagree with it but it's dishonest to argue that one service is violent coercive confiscatory fascism and the other is not.

And who said the doctors don't get paid by the government? This may come as a surprise, but there was a time when Medicare was the greatest cash cow ever. Although they weren't paid in gold ingots, so you could argue that they were never really reimbursed.

No.

people FAR too often confuse the word "right" with "privilege". By your argument, the afganis have a right to their guerrilla groups. These things are not rights. I have the right to pursue avenues in my life such that I do not infringe on someone elses rights. I also have the right to defend MYSELF. I do not have the right for someone else to defend me. Although, we can consider our military an extension of ourselves for these purposes.

We do not have a right to free healthcare. It is not the job of the government to fix all of your booboos, especially in the face of gluttony, excess, and vice. Our laws protect those who cannot protect themselves i.e. free pre-natal care. That isn't for the mother. Most "rights" can be summed up as a legislated version of the golden rule and how things would function if the world were to collapse. If the US fell apart right after I got my MD, you can bet I would require goods for my services. Supply and demand isn't a legislated concept. It is what happens when people need something that other people who need things have.

 

[jdh71]

If a Chinese tank is rolling down your street, do you feel that you have a right to military defense? I mean, the Army or Air Force guys were perfectly happy sitting around at base. When you make them come blow up a tank, just because you're too lazy to do it yourself, you're forcing unpaid labor on them.

Yeah, you're being paid to defend the country. Implicit in your agreement to be in the military is to blow up unwelcome chinese tanks.

That was a big swing and a miss.

 

[scarshapedstar]

if we can bring down the cost of everything by taking some of the fear of god out of hospitals of lawsuits I bet the current popcultural fanaticism about healthcare will wane a little

My problem with this is the empirical failure of "tort reform" in this regard. There is a logical disconnect between "less liability for insurance companies" and "lower premiums"; namely, the assumption that they will choose to make less money out of the kindness of their hearts.

They can just easily laugh all the way to the bank because they don't have to pay out as much.

Why should they do otherwise?

 

[SoulinNeed]

What's with the 30% cut talk? That's from the SGR cuts, not the healthcare bill. It's also been delayed over and over and over again, and likely will continue to be delayed. It's been getting delayed since Bush was in office.

 

[scarshapedstar]

Yeah, you're being paid to defend the country. Implicit in your agreement to be in the military is to blow up unwelcome chinese tanks.

Okay, but we are guaranteed protection as citizens. That is our right. He's fulfilling that. It's not just that he's paid to blow up tanks. I could pay my neighbor Bubba to do that, but it wouldn't have anything to do with the obligations of the government.

 

[Shakespeare37]

My problem with this is the empirical failure of "tort reform" in this regard. There is a logical disconnect between "less liability for insurance companies" and "lower premiums"; namely, the assumption that they will choose to make less money out of the kindness of their hearts.

They can just easily laugh all the way to the bank because they don't have to pay out as much.

Why should they do otherwise?

Caps on payouts is not the only way to reform med/mal law. Since government is already in the business of regulating what insurance companies are and aren't allowed to do, why not just flat out regulate their profits? Given that their profits have SKYROCKETED (http://washingtonindependent.com/62...-higher-than-nearly-all-fortune-500-companies) in recent years, go after them, AND put caps on payouts.
As quite a few posters have mentioned, this is a complicated issue and there is no easy solution.
The interesting thing to me is that nobody on this thread has brought up big pharma and drug prices. The fact that medications are more expensive in the United States than anywhere else in the world and that big pharma profits are usually around 17%, means there are some real opportunities for savings here as well. Please, spare me the R+D argument. Most data indicates pharm puts about 12% of their budget into R+D. They could put more and still have decent profits. http://money.usnews.com/money/blogs/flowchart/2009/08/25/why-health-insurers-make-lousy-villains Also to note here are the low profits of actual health insurance providers. Which makes me wonder where most of the money spent on health care is going.

 

[jdh71]

Okay, but we are guaranteed protection as citizens. That is our right. He's fulfilling that. It's not just that he's paid to blow up tanks. I could pay my neighbor Bubba to do that, but it doesn't have anything to do with the obligations of the government.

You could pay bubba to blow up tanks, but that would be kind of inefficient.

We aren't guaranteed "protection" as right, but as part of our social contract the government does do it's best to protect us. We don't have a "natural right" to be protected by someone else. This is the reason you can't sue the police if they don't show up in time after you call them and something bad happens.

 

[surftheiop]

Well, it's probably not good too make too many assumptions.

My sort of general position is one I think is interesting and nuanced. I'm actually more of an anarchist than anything, but have swung back around for practical purposes to a minarchist position at baseline that allows for negotiation and compromise . . . because we have to come up with a plan for dealing with the *****s, the criminal, and poor (and don't think because I've put them together there, I think they are the same thing [some are though]).

As such I see the natural rights argument as the most natural and correct, but I do appreciate there do exist other ethical systems, most of which, like Bentham's utilitarianism, tend to try and maximize the group over the individual, which I find repugnant. Yes, we are a social animal, but we are individuals who live in groups. We're not hives, or prides, or a congress . . . it's different. Protection of the individual is paramount in my mind, and negotiating a social contract from those limitations placed on government are important to me. The problem with the opposite is that it simply leaves no room for lines in the sand. If government, tomorrow, decided that baby rape was ok, then by the logic posited by my opponents in this discussion, it would be. I take the position that baby rape is ALWAYS wrong no matter what you, anyone else, or any government has to say about it. Lines in the sand.

I don't massively disagree with your points here (except the implication of the bolded). Contrary to the path I was taking, I actually do believe there exists an absolute objective morality, but I'm not convinced the the absolute right to your body/property is part of it. I also sort of think that understanding all parts of the absolute objective morality is sort of beyond our capacity so I'm not so concerned about ironing out all of the possible inconsistencies and would rather focus on figuring out what it means in a practical sense.

Back to the bolded. Most people who support the state don't give the state the unilateral ability to define morality. They think its a nuanced thing where there is an interplay between society, government, historical norms, some sort of utilitarian considerations and moral common sense (your construct of natural rights would be what I would lump into the moral common sense). The big question is if the moral common sense is actually consistent with any sort of natural rights. I imagine in 300 years everyone might think its blatantly obvious that healthcare is a natural right and will look back to us like we do to slave owners and egypt's pharaohs. So if in your opinion the natural rights are knowable and never change, there is some tension that happens if the entirety of societal moral common sense drifts so far from your current understanding of natural rights. Throughout history, pretty much all people think they know what is naturally right/wrong and we see it shift so much that I find it statistically unlikely that your particular understanding just happens to be the one out of thousands that matches some metaphysical target.

 

[scotchtapetest]

1 - do not expand mid-level provider privileges. I'm sorry, but primary care doesnt need to be flooded with people who are driven more by protocols and flow charts than by a workable understanding of the body and disease.

Well said; In fact IMO, primary care is the hardest specialty.... Now as we know, it is very easy to be a crappy PCP with just referring everyone with more than a stuffy nose to specialists but being truly a GOOD PCP, is very difficult as you need to know a good bit about everything.

As you said, mid-levels are great at following protocols, so is a computer program. We could replace all these newly developed protocols with a Google service; You put in your symptoms and it follows a checklist producing final results (either diagnosis or refer to someone else).

On a separate note, I think this whole concept of checklists/protocols for everything under the sun is really diluting the value of being a good physician....

Also, mid-levels are not just in primary care anymore; They are penetrating all specialties... In fact non-primary care specialties with lot of procedures are threatened more because mid-levels get to do all the procedures that require very little thinking... I was actually talking to a senior PA student the other day, and she thought going into IM is below her (prestige level and all that)....

2- along the same lines - monetary incentives for primary care. no more of this tuition reimbursement and loan perk crap for rural med. I mean increase payouts for primary care and decrease specialty payout. I say this with hesitation because I do not like primary care. I'm thinking something peds surg at the moment. However if i want to stop thinking of myself and think long term for a fix for medicine, shift the competition from ROADS to primary. There is just no real reason for derm to gross at the high end of specialty with a cush schedule and an ample supply of skin creams. I know there is more to it, but many derms in private are basically running glorified salons and making bank while getting reimbursed from insurance.

Amen to that!

IMO, a better argument would be that the disparity in pay should more closely mirror the difference in training time... I mean an IM sub-specialist should not be paid the same as general IM physician b/c they had more training, however, a GI shouldn't be paid 5x a general internist b/c their education is not 5x longer.

3- cut elective treatments and procedures from insurance. If someone wants to have something done because it is an irritant they can pony up. Maybe we can include some legislation for an applicaiton process for elective procedures..... (im thinking deviated septums here for example). something you don't need but may increase quality of life. we dont want to restrict practice or deny patients something they need, but we also don't need insurance and the government paying for crap just to make you comfortable.

To my knowledge most insurance companies don't cover true elective procedures... However, if it is affecting the quality of their life, then it should be addressed.... If we follow your argument it can be taken to extremes; For instance, viral URI is not really a medical necessity and any medication (e.g. decongestant) is only for quality of life improvement, but I think we all would agree that insurance should cover that.

But allowing for quality of life procedures/care can also be taken to an extreme, so I guess there needs to be a happy medium.

5- cap and revamp malpractice. negligence and quack docs suck, trust me I know. But every department in every hospital out here is spending too much time and energy covering their own asses or building up a buffer in the inevitability of a lawsuit. The ER doc i used to shadow hated ordering all of the tests for mundane things, but if he didnt a coincidental (and obviously unconnected to a physician) medical issue could hang both him and his hospital out to dry. this is unreasonable. IMO malpractice lawsuits should be capped at 100k (open to negotiation on that one) and the offending hospital is bound to provide free healthcare to the person related to the accident. If we wanna get all scientific lets look at functional losses - paralysis, dismemberment, ect, and compare rates in the general pop to within the hospital. Nick the brachial plexus of an award winning pianist? Sorry bro, you already had a 1 in XXX chance of losing that hand just going to work today, I'm not about to bankrupt this hospital so that you can continue playing pianoman trying to get into the pants of the nearest socialite. That said, up the ante for true malpractice - if you dun goofed... that happens. If a board of peers can prove that you were doing something really inappropriate, say unbundling your charges, over perscribing with a kickback, or getting knife happy to pay off a yacht... then you lose your license... this is already the case. The civil aspect of this takes into account the emotional factor of severity. Human error is random, not experimental, therefore it is constant. The likelihood that a surgeon will cut farther than he wanted to into a panniculus for a tummy tuck is similar to the likelihood that he will cut too far into a brain for a tumor (i'm ignoring other safety measures... but the point is a medical goof that ended up with little effect is no more or less serious than a medical goof that results in severe symptoms since both occur randomly with otherwise competent physicians).

if we can bring down the cost of everything by taking some of the fear of god out of hospitals of lawsuits I bet the current popcultural fanaticism about healthcare will wane a little

I think you have some good points about malpractice reform but I don't think that would have as much of an effect as you'd think. For instance in the ED physician example that you used, I don't think the reason for all those tests are fear of malpractice (that's more of an excuse). Under the current reimbursement models, ED physicians will continue to order all those tests, because fundamentally that's how they were trained. I've worked with physicians in very litigious states who barely ever ordered unnecessary test. They would document their physical findings and rational for not ordering a test and they have never successfully been sued (yet). If you are a competent physician who has been trained properly and provide the standard of care you are going to be fine...

The problem is that the reimbursement model is based on quantity of care versus quality of care. The ED physician brings more money for the hospital if s/he orders the unnecessary CT scan and frankly most of them don't know how to evaluate a patient with out it (it's part of their ABCs (airway, breathing, CT scan)).... However, if the government/insurance stopped reimbursing hospitals for all those CT scans they would drop dramatically.

Also the other contributing factor to unnecessary tests are health record mobility issues. Every time you go to a new doctor/hospital every single test that you've had done for the past 5 years has to be repeated because the records are not shared between healthcare systems.

As I said, although malpractice needs to be reformed, IMO changing the models for pay as well as improving health record mobility will have much higher impact on cost than malpractice reform.

 

[jdh71]

I don't massively disagree with your points here (except the implication of the bolded). Contrary to the path I was taking, I actually do believe there exists an absolute objective morality, but I'm not convinced the the absolute right to your body/property is part of it. I also sort of think that understanding all parts of the absolute objective morality is sort of beyond our capacity so I'm not so concerned about ironing out all of the possible inconsistencies and would rather focus on figuring out what it means in a practical sense.

Back to the bolded. Most people who support the state don't give the state the unilateral ability to define morality. They think its a nuanced thing where there is an interplay between society, government, historical norms, some sort of utilitarian considerations and moral common sense (your construct of natural rights would be what I would lump into the moral common sense). The big question is if the moral common sense is actually consistent with any sort of natural rights. I imagine in 300 years everyone might think its blatantly obvious that healthcare is a natural right and will look back to us like we do to slave owners and egypt's pharaohs. So if in your opinion the natural rights are knowable and never change, there is some tension that happens if the entirety of societal moral common sense drifts so far from your current understanding of natural rights. Throughout history, pretty much all people think they know what is naturally right/wrong and we see it shift so much that I find it statistically unlikely that your particular understanding just happens to be the one out of thousands that matches some metaphysical target.

At least since recorded history, we'll say in the last 10,000 years to be safe, laws have been recorded demonstrating that people agree killing and theft at minimum were wrong. Do you know of a society where these were not considered wrong. I don't think these things shift as much as you think you do.

 

[surftheiop]

At least since recorded history, we'll say in the last 10,000 years to be safe, laws have been recorded demonstrating that people agree killing and theft at minimum were wrong. Do you know of a society where these were not considered wrong. I don't think these things shift as much as you think you do.

The problem is I don't think you can say even modern society considers killing and theft inherently wrong. For example, today people don't universally agree that stealing an artists musical work or an actors TV show via the internet is wrong.

And in the case of killing, there is a huge spectrum of what is considered right/wrong by different people. Is it wrong to kill someone who is pointing a gun a your wife? Is it wrong to kill a thief who is running away with your wallet? Is it wrong to fight a war to end genocide? Is it wrong to execute a murder? Is it wrong to kill someone who trespasses on your property? Do any of these change if mental illness is involved?

I see no evidence that people are in agreement that theft and killing are inherently wrong.

 

[jdh71]

The problem is I don't think you can say even modern society considers killing and theft inherently wrong. For example, today people don't universally agree that stealing an artists musical work or an actors TV show via the internet is wrong.

And in the case of killing, there is a huge spectrum of what is considered right/wrong by different people. Is it wrong to kill someone who is pointing a gun a your wife? Is it wrong to kill a thief who is running away with your wallet? Is it wrong to fight a war to end genocide? Is it wrong to execute a murder? Is it wrong to kill someone who trespasses on your property? Do any of these change if mental illness is involved?

I see no evidence that people are in agreement that theft and killing are inherently wrong.

Well, "intellectual property" is actually probably not really a "real" property, so I don't know how you actually "steal" that, outside of the way the law is written.

Perhaps "kill" was the wrong choice of words. Murder would be a better choice.

We've always generally recognized that it follows from a right to property a right to self defense from those that initiate force and that force may be met with force.

 

[MT Headed]

At least since recorded history, we'll say in the last 10,000 years to be safe, laws have been recorded demonstrating that people agree killing and theft at minimum were wrong. Do you know of a society where these were not considered wrong. I don't think these things shift as much as you think you do.

The American Indian tribe a hour south of here does not consider theft wrong, if the tribe is the one performing the theft. Though I suppose without clear title to property, one might argue that no "theft" has actually taken place.

 

[surftheiop]

Well, "intellectual property" is actually probably not really a "real" property, so I don't know how you actually "steal" that, outside of the way the law is written.

Perhaps "kill" was the wrong choice of words. Murder would be a better choice.

We've always generally recognized that it follows from a right to property a right to self defense from those that initiate force and that force may be met with force.

This is minority stance held mostly by anarchocapitalists (and maybe communists!), so I don't think you can claim this is anything close to a universal truth.


And its easy to say you accept meeting force with force, so if a cop is arresting you for committing what you feel is a non-crime (lets say pirating a ton of stuff), is it morally OK to shoot the cops?

 

[MT Headed]

The problem is that the reimbursement model is based on quantity of care versus quality of care. The ED physician brings more money for the hospital if s/he orders the unnecessary CT scan and frankly most of them don't know how to evaluate a patient with out it (it's part of their ABCs (airway, breathing, CT scan)).... However, if the government/insurance stopped reimbursing hospitals for all those CT scans they would drop dramatically.

Washington State medicaid will not pay for emergency department procedures if the condition turns out to be non-emergent.

This puts emergency physicians in a bind... EMTALA requires the patient to be seen, but if the physician guesses a non-emergent patient is emergent there is no payment, and if the physician guesses an emergent patient is non-emergent they get sued.

It's a convenient method to transfer wealth from hospitals to the state, and transfer risk from hospitals to physicians. The state wins, the hospitals are about even, and the emergency physicians (the ones who chose to remain in Washington State anyway) lose.

 

[Concubine]

We have to be honest and say that US healthcare sucks in regard to infant mortality . Not sure how all of this can be solved, but a black/white perspective won't help anyone. Unfortunately this is exactly what the US is famous for - a polarizing country where most people either are like "wtf" or "omg iluv".

I don't buy this completely. Look into how they come up with the infant mortality numbers. It is very inconsistent across developed nations. In particular how the U.S. defines infant mortality, puts us at a great disadvantage when playing the statistics game. Do a google search on infant mortality. Like the saying goes, there are lies, damn lies, and statistics.

 

[SpecterGT260]

Well said; In fact IMO, primary care is the hardest specialty.... Now as we know, it is very easy to be a crappy PCP with just referring everyone with more than a stuffy nose to specialists but being truly a GOOD PCP, is very difficult as you need to know a good bit about everything.

As you said, mid-levels are great at following protocols, so is a computer program. We could replace all these newly developed protocols with a Google service; You put in your symptoms and it follows a checklist producing final results (either diagnosis or refer to someone else).

On a separate note, I think this whole concept of checklists/protocols for everything under the sun is really diluting the value of being a good physician....

Also, mid-levels are not just in primary care anymore; They are penetrating all specialties... In fact non-primary care specialties with lot of procedures are threatened more because mid-levels get to do all the procedures that require very little thinking... I was actually talking to a senior PA student the other day, and she thought going into IM is below her (prestige level and all that)....



Amen to that!

IMO, a better argument would be that the disparity in pay should more closely mirror the difference in training time... I mean an IM sub-specialist should not be paid the same as general IM physician b/c they had more training, however, a GI shouldn't be paid 5x a general internist b/c their education is not 5x longer.



To my knowledge most insurance companies don't cover true elective procedures... However, if it is affecting the quality of their life, then it should be addressed.... If we follow your argument it can be taken to extremes; For instance, viral URI is not really a medical necessity and any medication (e.g. decongestant) is only for quality of life improvement, but I think we all would agree that insurance should cover that.

But allowing for quality of life procedures/care can also be taken to an extreme, so I guess there needs to be a happy medium.




I think you have some good points about malpractice reform but I don't think that would have as much of an effect as you'd think. For instance in the ED physician example that you used, I don't think the reason for all those tests are fear of malpractice (that's more of an excuse). Under the current reimbursement models, ED physicians will continue to order all those tests, because fundamentally that's how they were trained. I've worked with physicians in very litigious states who barely ever ordered unnecessary test. They would document their physical findings and rational for not ordering a test and they have never successfully been sued (yet). If you are a competent physician who has been trained properly and provide the standard of care you are going to be fine...

The problem is that the reimbursement model is based on quantity of care versus quality of care. The ED physician brings more money for the hospital if s/he orders the unnecessary CT scan and frankly most of them don't know how to evaluate a patient with out it (it's part of their ABCs (airway, breathing, CT scan)).... However, if the government/insurance stopped reimbursing hospitals for all those CT scans they would drop dramatically.

Also the other contributing factor to unnecessary tests are health record mobility issues. Every time you go to a new doctor/hospital every single test that you've had done for the past 5 years has to be repeated because the records are not shared between healthcare systems.

As I said, although malpractice needs to be reformed, IMO changing the models for pay as well as improving health record mobility will have much higher impact on cost than malpractice reform.

That could be.... much of point 5 is a retort to people who think healthcare is so expensive because of Dr. Salary. That is ridiculous. Physicians make good money, but it is not outrageous nor it is largely offsetting healthcare expenses

 

[jdh71]

This is minority stance held mostly by anarchocapitalists (and maybe communists!), so I don't think you can claim this is anything close to a universal truth.

I think if you look at the topic from a philosophical point of view it can't be anything but true, but it's a side path we don't need to go down.

And its easy to say you accept meeting force with force, so if a cop is arresting you for committing what you feel is a non-crime (lets say pirating a ton of stuff), is it morally OK to shoot the cops?

Sometimes. Though, generally as part of the social contract we agree to allow law enforcement to arrest us provided we get a fair and timely trial. Outside of that context, false arrest I think can (and should) be resisted to the death.

 

[surftheiop]

I think if you look at the topic from a philosophical point of view it can't be anything but true, but it's a side path we don't need to go down.



Sometimes. Though, generally as part of the social contract we agree to allow law enforcement to arrest us provided we get a fair and timely trial. Outside of that context, false arrest I think can (and should) be resisted to the death.

You have good points, but my point is that society would not necessarily agree with you to the extent that you can say that theft/killing(murder) have been universally wrong for the last 10,000 years. I think all people would agree that what they consider theft/murder is wrong, but there is nothing close to universal consensus on what theft/murder are so effectively you can't say for sure society has a certain stance on theft/murder. I'm actually not certain what the relevance of this was to the general discussion anymore, but was just pointing out that I don't think these have been steadfast moral norms for the last 10k years (let alone today).

 

[jdh71]

You have good points, but my point is that society would not necessarily agree with you to the extent that you can say that theft/killing(murder) have been universally wrong for the last 10,000 years. I think all people would agree that what they consider theft/murder is wrong, but there is nothing close to universal consensus on what theft/murder are so effectively you can't say for sure society has a certain stance on theft/murder. I'm actually not certain what the relevance of this was to the general discussion anymore, but was just pointing out that I don't think these have been steadfast moral norms for the last 10k years (let alone today).

Well . . . at the expense of being terribly cliche' . . . we'll have to agree to disagree for now.

You have the kind of rhetorical skills that would make this conversation too time consuming right now!

Maybe we can do this again when I've got more time. Or not.

 

[henge]

At least since recorded history, we'll say in the last 10,000 years to be safe, laws have been recorded demonstrating that people agree killing and theft at minimum were wrong. Do you know of a society where these were not considered wrong. I don't think these things shift as much as you think you do.

Consider the issue of death by air pollution. People who drive vehicles cause pollutants to be expelled into the air. Let's assume, reasonably, that some of those pollutants are deadly to some people. See, e.g., http://www.nytimes.com/2009/10/20/science/earth/20fossil.html (20,000 premature deaths annually in US from transport and power related air pollution). Since drivers are killing people, and since at least some of the victims have not consented to being killed (arguably other drivers consent by the act of driving and killing other people and thereby agree to the risk of being killed themselves), how do you justify allowing people to drive at all, much less to drive vehicles that produce much more pollution than is technologically necessary to move a person from point A to point B? It seems to me pretty much all societies accept some level of killing, as deemed appropriate by each society to allow the society to function at a material level that most of the people in the society want. You can argue that indirect vs direct killing makes a difference, but from the point of view of the victim, whose right to life is presumably the reason for prohibitions on killing, it makes no difference. It seems you end up back at some form of utilitarianism or Rawls' social contract (ie., what would you agree to if you didn't know which side of the pollution transaction you'd be on).

 

[scotchtapetest]

Washington State medicaid will not pay for emergency department procedures if the condition turns out to be non-emergent.

This puts emergency physicians in a bind... EMTALA requires the patient to be seen, but if the physician guesses a non-emergent patient is emergent there is no payment, and if the physician guesses an emergent patient is non-emergent they get sued.

It's a convenient method to transfer wealth from hospitals to the state, and transfer risk from hospitals to physicians. The state wins, the hospitals are about even, and the emergency physicians (the ones who chose to remain in Washington State anyway) lose.

Just to be clear, EMTALA, says nothing about ordering a head CT scan for everyone that walks in or any other "cover my a**" tests". It just says that they have to get evaluated and their medical emergencies treated appropriately.

I'm not familiar with the specifics of WA state medicaid but that's a small portion of patients which require expensive workup in the ED... For the most part medicaid patients come in for the sniffles or chronic problems, none of which require expensive ED workup.... Most people who require expensive workup are seniors (with MEDICARE) and others with private insurance which do pay for the BS tests ED physicians order.... Also, if you pay close attention, you'll see that they get more tests as well (b/c someone will pay for it).

There is also federal aid that is handed out to these hospitals based on the number of uninsured/underinsured people they see. Furthermore, MEDICARE and private insurance compensate hospitals at much higher rates for ED procedures/tests that it actually costs (e.g. $1,000 b-hCG test is very common which costs <$100 in output setting) to offset the loss in those other cases. Now I'm not saying that EDs make bank, but it's not as bad as you make it sound and if they (medicare and private insurance) changed payment models, a good percentage of these unnecessary tests would stop.

 

[pupster]

If I do make it into medical school, I honestly don't care if they cut my salary because medicine should be a vocation, a calling, not a way to make a ton of money.

Oh Gawd...perhaps for you, but the reality is that medicine is a business w/ RVU and performace tracking, once you get beyond the Kool-Aid that it's a calling. If it's a calling to help others, why not just do social work or something else? The reality is that many physicians sacrifice 8+ years of their lives while their colleagues in other industries are making money. I have no problem being compensated well for my training, aptitude, and prior sacrifices.

 

[SpecterGT260]

Washington State medicaid will not pay for emergency department procedures if the condition turns out to be non-emergent.

This puts emergency physicians in a bind... EMTALA requires the patient to be seen, but if the physician guesses a non-emergent patient is emergent there is no payment, and if the physician guesses an emergent patient is non-emergent they get sued.

It's a convenient method to transfer wealth from hospitals to the state, and transfer risk from hospitals to physicians. The state wins, the hospitals are about even, and the emergency physicians (the ones who chose to remain in Washington State anyway) lose.

I feel like this is an oversimplification... either that or an example of why non-physicians should not be making these sorts of calls....

Sounds like a good place for a BS waiver form which outlines the shortcomings of current public office holders in regards to practice

 

[valkener]

At least since recorded history, we'll say in the last 10,000 years to be safe, laws have been recorded demonstrating that people agree killing and theft at minimum were wrong. Do you know of a society where these were not considered wrong. I don't think these things shift as much as you think you do.

The Dothraki of Westeros!

 

[SteinUmStein]

The Dothraki of Westeros!

He comes... the Stallion Who Mounts the World.

 

[jdh71]

I actually started reading the series. Don't post any spoilers.

 

[SteinUmStein]

I actually started reading the series. Don't post any spoilers.

Roger that. Good taste, you'll enjoy them.

 

[Instatewaiter]

If a Chinese tank is rolling down your street, do you feel that you have a right to military defense? I mean, the Army or Air Force guys were perfectly happy sitting around at base. When you make them come blow up a tank, just because you're too lazy to do it yourself, you're forcing unpaid labor on them.

If you're going to ignore "promote the general welfare" you might as well ignore "provide for the common defense" as well. There is nothing so special about healthcare that prevents it from being lumped in with everything else the government uncontroversially provides. You may disagree with it but it's dishonest to argue that one service is violent coercive confiscatory fascism and the other is not.

There is a distinction here that others have alluded to. There are 3 groups of "rights:" an innate right, a public good and all others. An innate right most people would not argue about: life, liberty, property.

Public goods are things that most also would not fight about- those things that are impposible or near impossible for people to provide themselves. This includes defense and infrastructure mainly.

The final are other "rights" which are controversial mainly because they are positive rights requiring someone else to provide those rights to you. The distinction between this group and the public goods group is that the "positive rights" could be provided in the public sector while public goods could not.


Here, health care differs from things like infrastructure or right to life because it is neither innalienable/innate nor a public good. The more conservative people, including libertarians, feel it is not the gov'ts place to provide such services.

I will leave you with a Jefferson quote that sums up nicely my stance: "The policy of the American government is to leave their citizens free, neither restraining nor aiding them in their pursuits." It is under this lens that the terms "promote the general welfare" should be viewed.

 

[valkener]

I actually started reading the series. Don't post any spoilers.

I read the books myself and look forward to waiting another 6 years for the next one to come out. Haven't watched the TV show yet.

 

[SteinUmStein]

I read the books myself and look forward to waiting another 6 years for the next one to come out. Haven't watched the TV show yet.

I was really surprised and impressed, the TV show is fantastic. I highly recommend checking it out if you're a fan of the books.

 

[Lysinee]

Are those books fun to read like Harry Potter books? I could read those books all day, lol.

 

[SteinUmStein]

Are those books fun to read like Harry Potter books? I could read those books all day, lol.

"Fun" would not be a good word to describe ASoIaF. "Entertaining" would be closer. They're definitely not for kids.

Edit: I thought of a quick way to describe them: take Lord of the Rings, drag it through a muddy field, and punch it in the mouth several times. That's pretty close. Oh, and give it a big incestuous kiss on the lips.

 

[valkener]

Are those books fun to read like Harry Potter books? I could read those books all day, lol.

Yeah they are a lot of fun! The characters have an immense depth to them, and are unpredictable. Protagonists die or go through hell, and new characters become important, etc. All of this is coated in beautiful prose and story-telling. Lots of adult material too, just like the TV show but obviously not as graphic.

 

[Lysinee]

SteinUmStein and valkener, thanks for the input.

 

[SteinUmStein]

Yeah they are a lot of fun! The characters have an immense depth to them, and are unpredictable. Protagonists die or go through hell, and new characters become important, etc. All of this is coated in beautiful prose and story-telling. Lots of adult material too, just like the TV show but obviously not as graphic.

There's my one-word descriptor I was looking for! Unpredictable!

 

[SteinUmStein]

Last post about books from me, I promise -

If you want a really fun read of the grown-up Harry Potter variety, I highly highly recommend The Name of the Wind by Patrick Rothfuss. Check it out.

http://www.amazon.com/Name-Wind-Kingkiller-Chronicles-Day/dp/075640407X

 

[Lysinee]

Lol, I only used Harry Potter as a reference because that's the last book I read outside of school. I guess school and Xbox has kept me too busy.

But, I will check it out in the future.

Last post about books from me, I promise -

If you want a really fun read of the grown-up Harry Potter variety, I highly highly recommend The Name of the Wind by Patrick Rothfuss. Check it out.

http://www.amazon.com/Name-Wind-Kingkiller-Chronicles-Day/dp/075640407X

 

[SteinUmStein]

Lol, I only used Harry Potter as a reference because that's the last book I read outside of school. I guess school and Xbox has kept me too busy.

But, I will check it out in the future.

Sorry, wasn't meant as a jab at you, I think Harry Potter's an amazingly well-written series. The Name of the Wind is probably my favorite fantasy novel that I've read in the past ~5 years (excluding Wheel of Time, another long story), not just recommended because of its tangential similarity with HP (the main character is a "wizard" of sorts).

 

[Lysinee]

It's all cool!

Sorry, wasn't meant as a jab at you, I think Harry Potter's an amazingly well-written series. The Name of the Wind is probably my favorite fantasy novel that I've read in the past ~5 years (excluding Wheel of Time, another long story), not just recommended because of its tangential similarity with HP (the main character is a "wizard" of sorts).

 

[CaptainSSO]

Maybe that person should have taken personal RESPONSIBILITY for his/her health and his/her career/education. Not my problem. I'm already paying $$$ in taxes to fund people who go to the corner shop and buy Slim Jims with our tax dollars "

Not everyone has that luxury. How about immigrants who work their asses off for 7 dollars an hour? If they need something like a major surgery a lot of them won't be able to afford it. This is like a typical "pull yerself up by yer bootstraps" mentality. For some people it holds true, for others, it doesn't.

 

[pupster]

Not everyone has that luxury. How about immigrants who work their asses off for 7 dollars an hour? If they need something like a major surgery a lot of them won't be able to afford it. This is like a typical "pull yerself up by yer bootstraps" mentality. For some people it holds true, for others, it doesn't.

Nobody forced them to come here. Nobody forces people (immigrants or not) to take certain jobs. Just like nobody forced me to study medicine. So, it's society's job to have to care for everyone? Sorry...Not My Problem. People have to realize that decisions have consequences.

 

[CaptainSSO]

Nobody forced them to come here. Nobody forces people (immigrants or not) to take certain jobs. Just like nobody forced me to study medicine. So, it's society's job to have to care for everyone? Sorry...Not My Problem. People have to realize that decisions have consequences.

Dude, WTF? Nobody forced them to come here?! So you'd be cool with ****ting in an outhouse and not having any running water? With being so poor you eat the same ****ty meal 6 times a week? People come here for a better life. Believe it or not Taco Bell pays a lot better than some jobs in developIng countries. Nobody forces them to take certain jobs? They don't have the privilege you do to be able to go to college or med school. Why the **** did you even go into medicine?

 

[SpecterGT260]

Dude, WTF? Nobody forced them to come here?! So you'd be cool with ****ting in an outhouse and not having any running water? With being so poor you eat the same ****ty meal 6 times a week? People come here for a better life. Believe it or not Taco Bell pays a lot better than some jobs in developIng countries. Nobody forces them to take certain jobs? They don't have the privilege you do to be able to go to college or med school. Why the **** did you even go into medicine?

It's also delicious

 

[CaptainSSO]

It's also delicious

It is. Win win situation.