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Price on life.

Discussion in 'Topics in Healthcare' started by Faebinder, May 26, 2008.

  1. Faebinder

    Faebinder Slow Wave Smurf
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    http://www.time.com/time/health/article/0,8599,1808049,00.html?cnn=yes

    Finally, someone in medicare is discussing the price of life. I get tired of medicare claiming broke and higher costs when it fully funds things like a Whipple procedure on a pancreas adenocarcinoma patient that does not want chemo. That's only adding 6 months to the patient's life yet the procedure alone costs over $120,000 to medicare (for those that are curious, the surgeon makes around $1,500 from it.. including free followup for 3 months.... so guess who is profiting after the costs).
     
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  3. futuredo32

    futuredo32 Senior Member
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    If we start rationing care to the elderly, we'll be no better than countries with socialized medicine. I hope that we don't start rationing care to the old people. Honestly, I think that the young and able bodied who choose not to purchase health insurance are a big part of the reason that we don't have more tax dollars to spend on the elderly and people who truly can't provide for themselves. If we're going to ration healthcare, let's ration care for those who choose not to provide for themselves.
     
  4. Faebinder

    Faebinder Slow Wave Smurf
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    You can't approach this from an elderly stand point... it wont work.. It's true that the highest cost of healthcare are the elderly... and lets be honest... they are the one that sink the ship called healthcare. If you want to enable the elderly to get ALL the treatments possible out there then you need to start raising taxes on EVERYONE.

    Regardless, I believe the problem does not lie in the elderly at the moment, it's in the ICUs (which many elderly occupy). The ICU is the money making machine of the hospital. If it was up to the hospital, it would open up many floors to be ICUs and place patients in there that don't need to be in the ICU. The key to reducing costs is reducing the need for them by not covering things that dont make sense to cover. The problem is that people who control on medicare are not physicians so they dont know what should be or should not be covered.
     
  5. futuredo32

    futuredo32 Senior Member
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    The article was about Medicare which covers the elderly, so it seems logical to me that it is to be approached from an elderly standpoint. I have had a similar discussion here on SDN, was it with you? Anyway, the elderly are the ones who paid for Medicare for 40, 50 years. They paid for their health insurance(Medicare) to cover their health needs after they turned 65. They weren't paying for partial care where someone decided how much their life was worth. I don't think the answer is necessarily to raise taxes on everyone. There are a lot of areas in the budget that can be cut first. (One example is Medicaid, foodstamps, Section 8 housing for those who choose not to work, but could absolutely be self sufficient). If we cut all of the fat out of the budget and still needed more money for our senior, I'd gladly pay more taxes. Today's elderly paid for our schools, our roads, our parks, and even the hospitals with their tax dollars. We owe them.
    I've mostly rotated at one hospital, so I'm sure my experience with patients in the ICU is far less than yours, but this definitely isn't the case at every hospital. Patients in our ICU absolutely need to be in the ICU. They are the sickest of the sick.
    What doesn't make sense to cover, in your opinion?
     
  6. Faebinder

    Faebinder Slow Wave Smurf
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    Simple.... GOMERS. I firmly believe some patients need the status GOMER. Before you start attacking this... remember.. medicare is a set amount of money.. what you give to a gomer you take away from others who can benefit from this money.

    E.g. A GOMER who come to the ICU with sepsis yet have renal failure, heart failure, had a stroke.. low mental status baseline to begin with and now you are fighting to kill the sepsis.. putting central lines ($$) and swans ($$), expensive antibiotics ($$) and pressors ($$), on TPN($$) and lipids($$) and all kinda special nurses ($$$), in the ICU for 3 weeks getting all kinda scans ($$$$) and labs now ($$$), and eventually he will be able to mumble and sit in a chair cause he didnt move to begin with... and will get sepsis again in 6 months probably from his decubitis wound or come back to the ER cause he cant eat that well and needs to have a peg ($$$$).

    When do you say enough.. you are milking the system to maintain a near vegetable. If his family likes him so much they should pay for it... he is simply sitting in a nursing home not moving or doing anything.. eating and breathing. Stop thinking of it as killing someone and think of it as withdrawl of life support.

    (Yeah, I know it's harsh to hear it from a doctor.. but that's the truth that no one wants to face. Oh we cant let the old man die.. nevermind he is hardly functional. Who are you to determine who dies?! Blah blah blah...)
     
  7. futuredo32

    futuredo32 Senior Member
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    The patient ("gomer":rolleyes:) PAID for the healthcare. You aren't giving him/her anything. The patient is getting the care he/she prepaid for with income taxes toward Medicare. To whom would you like to give the benefits from this money? The young who haven't paid into Medicare yet? The elderly paid into Medicare for years and years. Though you may not think caring for the elderly is money well spent, it's not your money, it's really theirs.
    This is a pretty extreme case compared to what was presented in the article. Nonetheless, no doctor can predict his future. Maybe he'll be back in 6 months, but maybe not.
    IMO, "enough" is when the patient says "enough." If the patient is unable to convey his or her wishes and didn't document their wishes when they were able, then it's when their families say "enough." It's not milking the system. Again, they already prepaid for the care.

    Would you also suggest withholding care for a child with severe birth defects for monetary reasons? A child that will need continual care, a child who will do nothing but cost taxpayers money and will never be able to contribute to society, should this child be denied care too? That child will need special education, which is very costly to tax payers as well.
    Or what about rehab for an addict for the 5th time. The addict will likely be back for rehab soon. The addict will possibly never contribute to society in any meaningful way. Should we pay for the addict?
    This is kinda off the topic of care for the elderly, just wondering what your opinion is in an instances like the ones I mentioned.
     
  8. Faebinder

    Faebinder Slow Wave Smurf
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    I am tired of hearing how they prepaid the system... they did not prepay for the costs of this decade.. they prepaid for the costs of the previous decades. Take the medicare paid 30 years ago and see if it matches up with inflation and investment for the amount of cost to medicare this decade. The costs have increased exponentially.. not linearly. So if I give you 5 dollars now.. will you pay 2000 dollars to my health 30 years from now?

    Worse.. your argument is pointless because the person I am asking you to PAY FOR also PREPAID... another medicare patient who needs different things done but are not covered because of costs.
     
  9. TheBee

    TheBee Scholl 2012, baby!
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    Do you think this problem with overspending at the end of life, even if just to prolong the life of a vegetable, could be solved if our culture adopted a healthier view of death?

    I think a lot of problems our healthcare system is in today stem from the fact we've decided that death is the ultimate bad, the end result that is the least desirable. It seems that nothing else is weighed against this. I know that this argument can be a slippery slope, and maybe doctors have to view death as the ultimate bad to perform at their optimum level. However, have you ever thought about what message that sends to patient families, to doctors? What that means as far as the resources we're willing to use to sustain life? I think about this a lot and I'm far from the answers, but I'm beginning to think our relationship with death is doing us more damage than good. I personally, knowing full well that I'm a living being who will die someday, would like to obtain a more positive outlook on death. But that's just me...
     
  10. Faebinder

    Faebinder Slow Wave Smurf
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    Absolutely.. this is the #1 issue... our outlook on death. Uncontrolled Diabetic? Yes... End Stage Renal Disease? Yes... Multiple Minor Strokes? Yes... Heart Failure from HTN? Yes........but God forbid you have a nonhealing ulcer that made you septic on top of all those diseases... no sir.. we gotta cure that and make sure you are barely alive with all those super morbid diseases... and let everyone pay for it with their taxes too.
     
  11. yaah

    yaah Boring
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    Rationing healthcare works very well until you (or someone you care for) is the one being rationed.

    Being put in the position of being the one who is staring death in the face will likely alter people's opinions. For some, that means they want less done and they just want to be left in peace. But for most, they want to fight it.

    And who is the one who decides what is rationed? GBMs (bad brain tumors) have a dismal survival rate. So does that mean we give up on everyone who gets one, because the extra year or two you give someone isn't worth the expense to everyone else? Or do you fight it hard in everyone who wants to because a small % will live much longer? Knowing policy makers, the rationing would have infinite numbers of exceptions and minutae to ensure that every politician or well connected lobbyist (or their family) would get the treatment, whereas joe schmo would not.

    Personally, I'd like to think that if I ever have a huge stroke and am left hemiparetic and aphasic I would just let nature take its course. But I don't know how I would feel if that happened to me. Maybe I'd still enjoy life and not want to give up what I can enjoy. Once you're gone, you're gone for good after all.
     
  12. elwademd

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    at some point, we'll realize that the finances to fund medicare and healthcare in general are not limitless. and at some point, we'll address it. hopefully.

    hard choices will have to be made, but they need to be made.


    once you get some more experience under your belt, you'll see there are a lot of patients like faebinder described. i can think of 4 patients like faebinder descrived off the top of my head on my last 4 week icu rotation one month ago!

    lately i've been wondering what would happen if you told the family that if you were to continue care, they had to put up some nominal fee. would that cut down on a lot of what we do.

    after all, there's plenty of things we can do to patients, but sometimes there's not much we can do for patients.

    i can pump grandma full of normal saline, chase it with zosyn, drop a central line, intubate her, get a consult for a peg placement, get another consult for a tracheostomy... but i can't undo the years of damage that hypertension and diabetes did to her blood vessels, her brain, heart and kidney; therefore i can't reverse her stroke and her cardiomyopathy. or whatever the case may be.

    but if there's no immediate financial cost to the patient/family, then there's really not much to think about, other than the hope for a full recovery. and that hope is fine. it's when that hope becomes irrational that you really start to wonder.

    when you have a 96 year old woman with a history of stroke, dementia, diabetes, hypertension who was admitted with pneumonia and renal failure... who then codes in the hospital... for 30 minutes... and has a systolic blood pressure of 80... on 3 pressors... and the family won't let go.. . you really wonder.

    most people aren't paying that much into medicare over their lifetime. if you really wanted to be technical, you'd only be able to get out what you put in. so, if you put in 50k over your lifetime, that's what you'd get, 50k worth of services. so the icu being 4k/day, you'd get 12 days before your family had to start paying out of pocket.

    but most people would say that's mean... or heartless... or financially sound... or a mix of all three. or maybe they'd say something else.

    but we (society) can't stop pretending that we don't need to sit down and truly address the issue of limited finances to fund healthcare. oregon is a state that is already trying to address this:

    http://healthcareorganizationalethics.blogspot.com/2008/04/oregon-health-care-reform-ethical.html
     
  13. futuredo32

    futuredo32 Senior Member
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    These people paid into Medicare with the belief that it would cover their future medical expenses. People are suing health insurance companies and WINNING when the insurance companies don't pay for needed treatment. Why should Medicare be any different? It's not the fault of today's seniors that the government didn't adjust taxes according when people started living longer, when medical care increased in price.
    Again, it's not the fault of the senior citizens that Medicare wasn't properly funded.
    You didn't answer my questions about how you feel about treating younger people who will never get "better" who will have nothing but years and years of medical costs paid for by tax payers. Do you support withholding care from them as well? Kids born with severe birth defects requiring one expensive surgery after another followed by one costly hospital stay after another. Kids who will likely never grow up able to work and pay one penny toward taxes to support themselves and others. Want to cut them out of the loop as well?
    What about the mentally ill who will never get better, who will spend much of their time in psychiatric wards, never able to work. Do you support denying them care too?
     
  14. futuredo32

    futuredo32 Senior Member
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    I'm sure there are plenty of people as ill as FB described, but that wasn't the typical patient described in the article. Asking relatives to pay? What if they have an ulterior motive? What if Aunt Ruth left them a lot of cash in her will and they'd rather she died today instead of waiting a few years? That would have the potential for a lot of abuse.

    If today's seniors didn't think that Medicare would be there for them in their golden years, if Medicare didn't exist, they could have invested their 50k. They didn't plan for alternatives because they assumed that Medicare would care for them. It's not right to tell them NOW that they need to pay more for their care. Do you expect an 80 year old to get a job to pay for healthcare?

    Just as I said to FB, do you support limiting kids to this amount too? A baby in the NICU born to parents with Medicaid , a baby who has never paid taxes and may never pay taxes, isn't likely to survive, how long do you want to let them get care paid for by the taxpayers before you ask the family to cough up the cash? Do you hope the baby will survive and earn enough to contribute 50k? Or do you want to be the one to ask the parents for 4k/day or else you'll have to pull the plug?

    What do you suggest we do about the woman who has kid after kid on Medicaid, lets taxpayers foot the bill for Welfare, WIC, and 18 years of Medicaid for each kid? How about illegal immigrants who have never and will never pay one dime in taxes?

    Reasonable hope for survival isn't a science. I don't have as much experience as many here do have, but I do know that doctors can be really really wrong with their predictions. I've seen doctors actually predict outcomes three times during my current IM rotation, twice, I've seen them tell family members that they expected the patient to make a full recovery only to have the patient die a few days later. On the other hand, we had a lady in her 90s with a very poor prognosis, the attending told those on his service that he didn't think she'd make it. She was in the hospital for a little over two weeks. Then, all of a sudden, she made a sharp turn around and started doing great. She went home- to her own home.
     
  15. Faebinder

    Faebinder Slow Wave Smurf
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    Alright tough guy/gal... you go ahead and play God.... tell us who will you not cover... cause last i checked... money is not growing on trees.. would you like to get taxed at 50%? How will you come up with that money? Please feel free to tell us where you are getting those funds from? All three candidates would love to hear your miraculous money making solution that they and their teams and the entire congress and senate couldnt come up with.

    And yes IMO if you paid a little.. you should get what you paid... it's not our fault the government UNDERESTIMATED the costs.. they are lucky it even TOOK medicare back then otherwise they would have had NOTHING today. (I am sure many did not even want to pay that tax when it came out but motivation is not a reason for denial.)
     
  16. TheBee

    TheBee Scholl 2012, baby!
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    You're right, the money does have to come from somewhere. We could either start regulating the amount of money spent on healthcare, or continue on our current path and pay a heck of a lot more in taxes.
     
  17. futuredo32

    futuredo32 Senior Member
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    It's gal, but I'm not tough.:)
    I asked you first.:p You want to limit the money spent on seniors, how about other groups? I sincerely want to know your thoughts on this. I will share my opinion on the subject, but please share yours as well.

    Who is at fault for the government underestimating Medicare costs then? Not the seniors. Why should they pay for idiots in Washington screwing up? Why should we? Someone has to pay. Washington should have raised taxes for Medicare modestly long ago. They didn't. I don't think paying 50% in taxes is necessary, (see below), but I'd be totally willing to pay 50% of my salary in taxes if it were necessary to ensure that seniors weren't denied care.

    You said that if we paid a little we should get what we paid for. Let's apply that to other areas.
    We all pay for things that don't benefit us or sometimes we benefit from things more than others that paid more. How many childless people pay property taxes so that other kids can attend public school? Can I be exempt from paying for school taxes if I don't have kids? Should people with three kids pay more to fund public schools than people with just one kid? How about people who send their kids to private schools, are they exempt? If a parent doesn't pay a certain amount of taxes, should we kick his kid out of public schools? How many millage increases to improve the local community college(that you have never attended) have you paid for? If I don't use the public parks, can I have a tax refund? You're willing to pay for all of that but not for seniors? I wasn't in favor of invading Iraq, but I'll probably be paying for that until the day I die. We, the taxpayers, pay for Washington's mistakes. We don't get exactly what we pay for. Some of my tax dollars will never benefit me at all, yet I still pay. We all pay for things we may not use. Because we pay for them, we have the right to use them. Stating that seniors should get the exact amount they paid into the system doesn't make sense when you compare it to all of the other things that we pay taxes for unequally(and also considering that their Medicare money is funding our residency programs.)

    I don't propose rationing care, but if we are going to ration care, I absolutely would not ration care to seniors who had a reasonable expectation that Medicare would cover their healthcare needs when they got older. Most seniors are currently unable to do anything to change their financial situation. They can't get a job tomorrow to cover higher medical costs.

    IF we are going to ration healthcare, let's alert everyone that Medicaid eligibility is now going to be very stringent and only be granted to those who absolutely can not provide for themselves. Give them a chance to take responsibility for themselves. IF we are going to ration, let's deny care to the young and able bodied who choose not to get healthcare. IF we are going to ration care, let's make hysterectomies a requirement for getting Medicaid/food stamps/WIC. If a woman has one child she can't afford, let's make sure it stays at one. IF we are going to ration care, let's deny care to illegal aliens who aren't paying taxes at all to fund healthcare for themselves or others. IF we are going to deny care, let's stop treating "John Doe" for Chlamydia in the ER. Let's make the ER a place for people with actual emergencies. Let's make "John Doe" use his real name and spend real money at a primary care office to get treated for his STD.

    Doctors and future doctors should all be grateful for Medicare. Where would the funding for our residencies come from if not from Medicare? We, as future physicians, are benefitting from Medicare. We are taking money from Medicare that could otherwise be used for the seniors healthcare. Many seniors may not live long enough to benefit from the services of today's residents. Most seniors have physicians who graduated from a residency program long ago and they don't need new doctors to be trained. They are paying our salaries as residents. Today's residents are going to be treating some people that haven't even started paying into Medicare yet. WE are benefitting from funds paid by the very people to which you think healthcare should be denied.

    I think I mentioned alternatives to rationing care or raising taxes to 50% the last time we discussed the topic. Instead of rationing care, we could raise the age limit for Medicare to 68. We could actually crack down on those abusing Medicaid. We could work on malpractice reform. With so many alternatives, why are you so quick to want to deny seniors care that they had every reason to expect that they would receive?
     
  18. Faebinder

    Faebinder Slow Wave Smurf
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    There is a huge difference between denying care and giving useless care... You look at it at not giving something vital to survive.. I and others at my level look at it giving useless care. When I say useless that doesn't mean the patient is actually functional. Truly vegetable status.

    You seem to be not distinguishing between Medicaid and Medicare. Who would you deny medicare? The young? What young? Medicare doesn't cover the young? Only old and disabled. You want to raise medicare to cover 68 instead of 65? That's crazy without making retirement age at 68... good luck making the american people retire at 68 instead of 65.. lets see how fair you are being to this generation who has to work for a long period of their life to maintain the older generation.. nevermind the value of their $ being weaker. Basically your suggestion says, lets take more money from the current generation to maintain the older one. Technically.. you are telling everyone that they will sit for 3 years with no insurance when they retire... at a real dangerous age when cancer kicks in (median age for many cancers is 65).

    You offer no solution while still staring at the problem. Feel free to deny more people healthcare to maintain vegtables...

    We agree to disagree at this point... I find your stance extreme, impractical and simply unreasonable.
     
  19. EUA

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    This whole concept of "paying into Medicare" over the previous 20 years is absurd. Medicare is NOT Social Security; Medicare is financed by federal income taxes, payroll taxes, a TAX on Social Security benefits, and member-paid premiums.

    But I digress. We as a country simply cannot continue funding the health care habits we have developed. The Holy Trinity of health care finance is composed of Costs, Quality, and Access to care. They are intimately interrelated. You want everyone to have equal access to care? Costs will rise, and quality will decrease. You want superior quality care with the latest and greatest tests, imaging studies, and medication? Your costs will skyrocket and, accordingly, access to care goes down. It's not complicated, but the government sure as hell doesn't get it, and sadly, neither do many health care providers. It goes without saying that the consumers don't get it.

    Americans have this warped view of health care with equally warped expectations. We think that the latest and greatest technology magically equals superior care, and consumer demand has only fanned the flames of engineers and pharmaceutical companies who are practically frothing at the mouth for the profits. (Case in point: Direct-to-consumer pharmaceutical advertising.) No where else in the world can Average Joe walk into an ER off the street and have the best imaging and therapies money can buy, but somehow we think that is an appropriate standard of care. And the public wants to blame the providers for escalating health care costs!

    Furthermore, Americans have about zero interest in preventative care or health maintainence. There is little cultural emphasis placed on a healthy lifestyle and healthy choices. Therefore, people cruise along, not taking care of themselves, until a real health crisis lands them in critical condition in an ED, such as those already described by previous posters. Then, somehow, the magic of technology is supposed to swoop in, deux ex machina style, and miraculously save the day. (Of course, when Grandma croaks anyway, it's the provider's fault. If she makes it, it's God's miracle.)

    You put all this together and we have billions of people who don't take care of themselves but want the most cutting edge health care on the planet on demand for cheap.

    Huh?

    So what do we do? Do we ration care? Well, define ration. Maybe it's not appropriate to use odansetron for every single hospitalized patient with a bit of an upset tummy, when phenergan would do the job for pennies? Is the patient getting phenergan getting crappy care? Of course not. We, as providers, simply must be cognizant of costs and be thoughtful in our choices.

    Most importantly, we desperately need a cultural shift in beliefs surrounding health care. As a society, we need to emphasize the importance of taking care of oneself and taking responsibility for one's own health. We also need to become realistic with our expectations and conquer our fear of death. No one is going to live forever, no matter how great their care is. Outcomes are not always going to be ideal, and an unwanted one doesn't mean that the provider or hospital is incompetent. If the public would simply stop looking to point the finger at someone when a loved one is ill, providers could stop practicing in fear. Can you imagine how reasonable our costs could become if we were liberated from defensive medicine? This magical "universal coverage" pipe dream could even have a chance of becoming a reality.
     
  20. futuredo32

    futuredo32 Senior Member
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    You started off this thread suggesting that Whipple procedures be denied to patients due to cost. Another thread you started on a very similar topic suggested that Medicare patients be limited to a certain amount of dollars. I'm really not sure that you just want to deny care to patients in a vegatative state. The elderly seem to be the group to whom you think care should be denied.
    Racism in this country is not accepted in most circles. Ageism is, unfortunately, alive and well. Our 'healthcare crisis" is not limited to those on Medicare. Suggesting that we only ration care to the elderly just seems incrediblly ageist to me. (hence the reason why I asked what you would do in other instances where patients who were younger didn't have insurance, didn't have any expectation of recovery) People on Medicaid are a huge cost to society. People on Medicaid who choose not to get health insurance are receiving healthcare at your expense and mine without contributing to the cost themselves in many cases. Rationing care to the elderly would be a small band-aid on a large wound and would be ageist. Who says people would have to sit for three years without insurance? They could work until they are 68 instead of retiring at 65.
    I have offered solutions. I don't know how you missed them. :confused:

    If you're done discussing this issue, that's fine. I really just can't agree with ageism any more than I can agree with racism or sexism.
     
  21. MOHS_01

    MOHS_01 audemus jura nostra defendere
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    futuredo,

    Medicare is a "pay as you go" program; while pretty much everyone agrees that it is unfair to all involved that the good ol' guv'ment (mostly dems) mouths wrote checks that their a**es could not cash, the premise that "they paid in for their care" is fundamentally incorrect.

    Healthcare is a commodity and, as such, will require a degree of rationing unless unlimited funds are to be poured into the system. Cost effective care must be the guiding principle in order for any system to work. This does not necessarily mean outright rationing; rather, think of procedures being treated as prescription drugs with different tiers of payment. This will not be limited solely to seniors and Medicare; in fact, I would imagine that MC will be one of the last payers to implement said changes out of a lack of political will.

    Oh, and for what it's worth -- everyone on this board will be paying 50% of many of their earned dollars in total taxes before it is said and done (FICA, SS, MC, state, local, property).
     
  22. AwesomO

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    This is true. The only way to save Medicare and SS is to increase taxes or get rid of all money sink holes in Washington. So of course it's going to be a tax hike:laugh:

    At some point the voters (if not caught up in trivial issues) are going to half to decide if they want to have all these social programs and have the govt take half their paychecks to taxes or decide that they want to keep more of their pay checks by getting rid of some programs.
     
  23. GassiusClay

    GassiusClay PGY-2
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    Thank you.

    Americans need better information on end of life issues. For example, the discussion of DNR should be brought up by a certain age. Not saying someone has to sign a form, but at least make people think about the costs of being kept alive.

    A 70 some year old trach vent peg sacral ulcer septic demented pt should not have a miserable quality of life prolonged. I think 99% people agree that continued care for such an individual is not effective and cutting costs for something else would be better.

    Rationing care is a reality that the whole world faces now. Socialized systems have somewhat dealt with it. America. No. Keeping "gomers" alive with multiple devices is not medicine. It's just plain inhumane. Respect mortality.
     

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