Fiscal Cliff and Doc Fix

[BLADEMDA]

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[glorfindel]

Government has an obligation to be a good steward of taxpayer money. Do you honestly think that is the case right now? Why does government have the right to take my money and give it to solyndra ,Green energy Companies or Windmill farms? Who decides how large the safety net needs to be? Should it include half of America?

Also, what is the role of government in society? We have vastly different views on that fundamental role.

I don't think the government is a good steward of our money right now, but I think we disagree about where the government is wasting it. Compared with Solyndra, the amount of tax money spent on healthcare is so much more significant. That needs to be cut, and I don't think we can get there by reducing the number of people on Medicaid.

The role of government in society, in my opinion, is to provide an environment full of enough common goods (sewers, police, open space, etc.) so that each of us can have a decent life if we're willing to work for it. I think protection from arbitrary private economic power is one of those common goods, and here I disagree with the libertarians. They're good at pointing out the dangers of government power, but blind to the dangers of private power.

I disagree with the social conservatives because I oppose theocracy. The law and religious morality are and should be different things, because there is no universal religion.

I disagree with the stereotypical liberal because I support the "make my day" laws. I acknowledge the presence of lazy bastards who want things handed to them in exchange for nothing. I think these people should be told "no, you lazy bastard, get a job." And I think that "big government" is a real danger.

So I suspect we have some real disagreements, but that they aren't as huge as they often seem. I think our disagreements are primarily

a) cultural.
b) about the relative danger of big govt vs the Koch brothers and Goldman Sachs
c) how much safety net is required for fairness, and how much is just for coddling lazy bastards.

 

[glorfindel]

Look at how much more expansion there is in the "medical care" category compared with all the others!

Somebody in the health care industry is making too much money. Who is it? Let's track them down, and cut their revenues to the bone.

I've said this before, as I recall....

 

[BLADEMDA]

Look at how much more expansion there is in the "medical care" category compared with all the others!

Somebody in the health care industry is making too much money. Who is it? Let's track them down, and cut their revenues to the bone.

I've said this before, as I recall....

It isn't the reimbursement per patient visit; it is the number of patients and number of visits/procedures which are skyrocketing.

Medicare needs reforming as proposed by Paul Ryan. Patients need skin in the game.

As for cutting Anesthesiologist reimbursement for Medicare please recall that I receive only 30% of my usual and customary fee from CMS vs a typical HMO.

 

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[pd4emergence]

Look at how much more expansion there is in the "medical care" category compared with all the others!

Somebody in the health care industry is making too much money. Who is it? Let's track them down, and cut their revenues to the bone.

I've said this before, as I recall....

The problem with your plan is that taking Medicaid/Medicare is not mandatory. Hospital based specialties have little choice. But cutting Medicare/medicaid reimbursements to physicians will only result in less physicians accepting Medicare/Medicaid. At some point it will be more expensive for a physician to accept both of these programs than it would be for them to not.

 

[doctor712]

It's good to finally watch a debate from the sidelines...

D712

 

[glorfindel]

The problem with your plan is that taking Medicaid/Medicare is not mandatory. Hospital based specialties have little choice. But cutting Medicare/medicaid reimbursements to physicians will only result in less physicians accepting Medicare/Medicaid. At some point it will be more expensive for a physician to accept both of these programs than it would be for them to not.

So, as I read your post, you're saying that the doctors aren't making too much money.

Who is, then? Private insurance companies? Hospitals? Pharmaceutical companies? Nurses?

 

[glorfindel]

It isn't the reimbursement per patient visit; it is the number of patients and number of visits/procedures which are skyrocketing.

Medicare needs reforming as proposed by Paul Ryan. Patients need skin in the game.

As for cutting Anesthesiologist reimbursement for Medicare please recall that I receive only 30% of my usual and customary fee from CMS vs a typical HMO.

I'm not opposed to making sure patients have skin in the game.

But for that to happen, patients are going to start asking me how much my proposed treatment plan is going to cost. "How much is that CT scan gonna be, doc?" "If you get that second set of cardiac enzymes on me, how much is that gonna be?"

Right now, I have no way of answering them, because there is no reliable sticker price for anything. The charges are calculated after the service has been performed. I have to tell my patients "I have no F***ing idea."

As for relative reimbursement between CMS and HMOs, your point is well-taken. We can't just tell everyone to go get an HMO, though, because the expenses are too damned high. People can't afford them. That's why there's so many uninsured, esp. in the under-65 crowd.

So our choice is not between HMO vs CMS, it's often between CMS and uninsured. I'll take CMS any day given that choice.

 

[BLADEMDA]

Fiscal deal includes estimated $12.1 billion in tax credits for wind energy industry

Read more: http://www.foxnews.com/politics/201...in-tax-credits-for-wind-energy/#ixzz2GrazTN2f

 

[yappy]

Private insurance isn't that bad. ~100 dollar / month for many younger adults. People don't have it because they choose not to.

 

[PikminOC]

so why do poor people have smartphones, flat screens, their nails and hair done, etc?

is this really necessary for survival? really?

the poor people in our country live like rich people in other countries...

 

[doctor712]

Private insurance isn't that bad. ~100 dollar / month for many younger adults. People don't have it because they choose not to.

I'm not worried about the younger, single adult just out of Duke who can work for 15$ an hour, have a movie, watch a football game and pay 75$ for health insurance. (are you single and young?) When my WGA insurance lapsed, I had to pay $1200 a month for a family of four. With ASININE co-pays and deductibles to keep that insurance. Recently, I checked, and private insurance would cost me 600$ a month for the same. That's 7200 a year, gotta make ~12K just to pay for that. INSANE. So, if you are making 120K, that's 10% pre-tax, even at 240K, that's 5% pre-tax of one's entire income. That's the situation that frustrates me.

so why do poor people have smartphones, flat screens, their nails and hair done, etc?
is this really necessary for survival? really?
the poor people in our country live like rich people in other countries...[

Very true. Very very very true. Go to Brazil or France or UK and see how people live on 50K US a year. They're not packing their houses with Chanel bags and Samsung 9000 level TVs.

D712

 

[yappy]

We've established what it costs for health insurance... now lets examine the cost of NOT having health insurance...

That's the problem - everyone assumes if they show up to a hospital there will be a team of professionals ready to treat them - imagine if you or a loved one straight up died for not being able to have cover your bill or not having coverage? Would consider that price of not having health care too high? Once you remove the presumption that HC is free the cost of having health ins seems mute compared to the price of not having it.

Then when we consider the larger issue of cost-shifting the whole source of the problem comes into focus...

I'm not worried about the younger, single adult just out of Duke who can work for 15$ an hour, have a movie, watch a football game and pay 75$ for health insurance. (are you single and young?) When my WGA insurance lapsed, I had to pay $1200 a month for a family of four. With ASININE co-pays and deductibles to keep that insurance. Recently, I checked, and private insurance would cost me 600$ a month for the same. That's 7200 a year, gotta make ~12K just to pay for that. INSANE. So, if you are making 120K, that's 10% pre-tax, even at 240K, that's 5% pre-tax of one's entire income. That's the situation that frustrates me.



Very true. Very very very true. Go to Brazil or France or UK and see how people live on 50K US a year. They're not packing their houses with Chanel bags and Samsung 9000 level TVs.

D712

 

[glorfindel]

That's the problem - everyone assumes if they show up to a hospital there will be a team of professionals ready to treat them - imagine if you or a loved one straight up died for not being able to have cover your bill or not having coverage? Would consider that price of not having health care too high? Once you remove the presumption that HC is free the cost of having health ins seems mute compared to the price of not having it.

So do you think the problem is that people aren't willing to spend 25% of their income on health insurance? 50%? 75% 99% At what point do you (if you ever) say, "it's economically rational for this person to say 'that health insurance is too expensive and so I'm not going to buy it.'"

I hesitate to cast scorn on someone whose health care insurance options require them to pay such a large percentage of their already-modest income for health insurance.

Then when we consider the larger issue of cost-shifting the whole source of the problem comes into focus...

Yes, it does; the problem is... please enlighten us. I thought you were going to say "the problem of cost shifting is cost shifting" which is the strongest argument for single-payer that I've heard. You support single-payer then?

 

[glorfindel]

It's good to finally watch a debate from the sidelines...

D712

Apparently it wasn't that good c/w being on the field... 🙂

 

[CambieMD]

I'm pretty sure this isn't a big problem relative to the other spending problems we have.

1) medicare/medicaid. Huge, and growing. Biggest chunk of nondiscretionary spending. Costs can't be controlled, because one person's cost is another person's revenue. Who's making too much money in healthcare? Hospitals? Insurance companies? Doctors?

2) military. Biggest part of discretionary spending. Yet anytime anyone wants to cut military spending, the (mostly) GOP starts screaming that we're "crippling" our military. Really?

3) Cheesy special-interest perks, exemplified in D712s post. If you've got an effective special-interest lobby, the govt subsidizes you, no matter how unneccessary.

Compared to just these three, "lazy people" are a drop in the bucket.

I agree. What do the folks out there think the Bush tax cuts did to the deficit. The deficit grew. I view myself as a benificiary of entitlements.

Does anyone out thereknow how much the F-35 will cost this country.

Everyone says that the budget should be balanced but everyone wants their milk,cookies,ice cream and cake, also.

Cambie

 

[yappy]

We're in agreement that cost shifting is a problem; however, I think that denying care would go further in helping with cost shifting than a single payer system. That would bring the price in line with what it really costs for the paying individual. The problem isn't a multi-payer - it's no payers driving up costs by stiffing providers / hospitals. Once they're removed from the system a reliable fee-for-service can be established - you'll be paying for only your own care. As a result more people will be drawn into the health care market as consumers because prices will reflect individual costs.

Yes, it does; the problem is... please enlighten us. I thought you were going to say "the problem of cost shifting is cost shifting" which is the strongest argument for single-payer that I've heard. You support single-payer then?

 

[pgg]

Fiscal deal includes estimated $12.1 billion in tax credits for wind energy industry

What's the price tag of our oil-supply-guaranteeing Middle East policies?

Burning black stuff is only "cheap" because of the way we externalize the costs.

I don't have a real strong opinion on wind subsidies, but maybe spending money to nudge industry in a direction that favors our nation's strategic interests is something the government ought to be doing?

 

[cincincyreds]

Fixing medicare and social security is actually very easy. Just raise the age to collect benefits. I think social security is now 62, how about making it 65. And to max social security make it 75 instead of 70. I'll bet that should fix it.

Now for medicare, instead of 65, make it 70. I'll bet that should balance it. Sure, people have to work an extra five years, but I really see no issue with that.

Since people live longer, we just need to adjust numbers. I really don't think it is a big deal.

 

[glorfindel]

The problem isn't a multi-payer - it's no payers driving up costs by stiffing providers / hospitals. Once they're removed from the system a reliable fee-for-service can be established - you'll be paying for only your own care.

(bolding is mine)

How about if they're crossing the street and get hit by a truck? No SICU for you! You can't pay for it!

Seems a tad uncivilized.

 

[BLADEMDA]

I agree. What do the folks out there think the Bush tax cuts did to the deficit. The deficit grew. I view myself as a benificiary of entitlements.

Does anyone out thereknow how much the F-35 will cost this country.

Everyone says that the budget should be balanced but everyone wants their milk,cookies,ice cream and cake, also.

Cambie

1. Taxes are a necessary evil. The money I earn belongs to me and not the IRS. Allowing me to keep more of my own money is not an entitlement.

2. Defense- Sorry PGG but we have too many foreign bases and spend too much on defense. I'd advocate for a freeze on defense spending ( i do like the F-35 though)

3. No Cake, No Ice Cream, but Milk is okay- Cut it all and spare nothing

 

[pgg]

2. Defense- Sorry PGG but we have too many foreign bases and spend too much on defense. I'd advocate for a freeze on defense spending ( i do like the F-35 though)

Why apologize to me?

Posted in this thread, earlier today:

For the record, I favor cuts to the military, health care, and social security, and I don't oppose raising taxes for everyone.

🙂

 

[pd4emergence]

So, as I read your post, you're saying that the doctors aren't making too much money.

Who is, then? Private insurance companies? Hospitals? Pharmaceutical companies? Nurses?

I have always heard that physician reimbursement makes up about 20 to 25 percent of the cms budget. Doctors aren't making much off of Medicare/Medicaid compared to other insurers. I think the "doctors make too much" debate is a separate issue. As for anesthesia, we are reimbursed 30% of what a private insurer would have paid. Not 30% less but a true 30%. Most specialties and primary care it's more like 60 to 80%. Anesthesia folks take Medicare because we don't really have much of a choice. We are a hospital based specialty and pretty much take care of everybody who walks in the door. Doctors with their own clinic do have a choice. All I'm saying is that there is a certain level of reimbursement that will make these independent businesses decide they can no longer afford to take what cms has to offer.

 

[glorfindel]

I have always heard that physician reimbursement makes up about 20 to 25 percent of the cms budget. Doctors aren't making much off of Medicare/Medicaid compared to other insurers. I think the "doctors make too much" debate is a separate issue. As for anesthesia, we are reimbursed 30% of what a private insurer would have paid. Not 30% less but a true 30%. Most specialties and primary care it's more like 60 to 80%. Anesthesia folks take Medicare because we don't really have much of a choice. We are a hospital based specialty and pretty much take care of everybody who walks in the door. Doctors with their own clinic do have a choice. All I'm saying is that there is a certain level of reimbursement that will make these independent businesses decide they can no longer afford to take what cms has to offer.

Your points are all well-taken. I think any discussion of "what doctors make" has to account for the differences in doctors, b/c some of them make huge amounts of money, and some can barely cover their overhead.

Nonetheless, if we're talking about health-care spending, and if we agree that federal health-care spending is too high, we have to specify where it should be cut. Every dollar spent for health care is a dollar that someone in the health care industry counts as revenue.

So if we're going to cut spending, we have to decide whose revenue has to be cut.

Since I asked the question, it's only fair that I give a first tentative answer.

1) pharmaceutical and medical-device companies. As an industry, they have one of the highest profit margins in the country. They often claim that if their profits are cut, say, from 10% to 5%, that they will be unable to fund research for new, lifesaving medications, but this is clearly absurd, for many reasons that most of you are already well aware of.

So let's cut pharmaceutical-industry revenue. A good way to start is to allow CMS to negotiate for lower prices per unit purchased. My understanding is that they are prohibited by law from doing this now ( a win for the PhRMA lobby and a loss for the country).

2) Health insurance companies. This is less of a juicy target then pharma, because they are in a slightly more competitive market environment already. I'm less knowledgeable about how to cut revenue for these guys, but I suspect that others on this board have some ideas.

3) Lawyers. This is red-meat for the conservatives so I'll throw it in because I'm a bipartisan kind of guy. Federal tort reform, EMTALA reform, etc. that relieves the pressure on physicians to spend other people's money like drunken sailors because the personal liability risk for a less-than-optimal outcome would cut revenue to the hospitals and pharma firms.

Overall, I think it's absurd not to look abroad for ideas, because other advanced nations have succeeded at taming costs where the US has failed. Their medical outcomes are better in many (most) ways. I have yet to read a convincing explanation of this from the "get government out of my medicare" crowd in the US, but if I ever hear one, I suspect it will be something like this:

People in this country have been convinced that the medical-industrial complex can and should solve all their problems. In pain? There's a pill for that. Too short? There's a pill for that. Feeling sad? I can do a 5-minute procedure in my office under general anesthesia that will make you happy forever!

Culturally, we have to do two things simultaneously:

1) commit ourselves to saying "no" to people with unpleasant sensations, unfulfilling sex lives, and chronic hair loss, e.g. "life is pain. Go exercise. Medicine cannot fix you." Conservatives are good at this. Liberals suck at it.

2) commit ourselves to saying "yes" to poor people who get hit by trucks, need a primary doctor to help them manage their diabetes, or throw a blood clot to their MCA. That's civilized, it's compassionate, and it isn't being done very well now, because these people can't pay much. Conservatives simply want these people to go untreated, or if they treat them, they want to bankrupt them. Liberals are good at this.