Views on Healthcare Reform and Psych

[digitlnoize]

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Having looked over some of the health care plans on the table, I'm curious how the Psych community views them.

Many of the plans seem to place a decent amount of emphasis on mental health, and provide coverage under the new federal insurance system/guidelines.

How do you guys feel this will impact your practices? Do you think you'll see a rise in salaries, due to an increase in patients with insurance? Or not?

Do you think that psych will be included under the "preventive care" umbrella when payment restructuring is all said and done? Most of the talk about prevention has focused on diabetes, heart disease, etc, but do you see psych getting lumped in here?

Other views/thoughts?

 

[whopper]

I am happy that there will be increased mental health coverage, however I am fearing that the increased spending will not be done efficiently, and that the greater economic impact may lead to further pain & suffering down the road.

This example is on the extreme end, but would it be worth it to bankrupt an entire nation to pump all its money & resources into a possible cure for HIV that may yield no success?

Take that extreme to a lesser level. Our current economy is already in a weak state, our government has just unleashed a torrent of spending, and it wants to start a healthcare program that will dramatically further increase spending.

I can see this possibly dramatically increasing our inflation, & putting us on further dependency on China to buy up our debt.

Another problem I have with our current healthcare state is I don't see many plans emphasing personal responsibility. IMHO if our healthcare were to change in a manner that allows healthcare providers to provide more education to patient, teach them healthy lifestyles, give them incentives to live healthy, and inform them better on end of life options, that would dramatically reduce costs while improving the general health of people in our nation.

 

[digitlnoize]

Another problem I have with our current healthcare state is I don't see many plans emphasing personal responsibility. IMHO if our healthcare were to change in a manner that allows healthcare providers to provide more education to patient, teach them healthy lifestyles, give them incentives to live healthy, and inform them better on end of life options, that would dramatically reduce costs while improving the general health of people in our nation.

Agreed 100000000%. My main concern about this entire process (and I've written MANY letters to this effect) is that there isn't any personal responsibility for one's health under universal healthcare.

Where's the impetus for a person to quit smoking, if the lung cancer bill is paid for. I can hear them now..."Naw, I ain't gonna quit smokin'. If I did get cancer, which I won't 'cause my daddy didn't, but if I did, the government is payin' to get it taken out. Why should I quit?"

Sigh.

 

[BabyPsychDoc]

Whopper, I agree with your post in general, and I love your idea of personal responsibility in particular. I am just afraid it never will be implemented to any significant extent for several reasons:

1) It is not going to be popular with the majority of voters.
2) The cost of running it will likely outweigh the potential savings (eg, seeking confirmation for provided info may be both awkward and expensive).
3) In many instances the concept of personal responsibility gets blurred sufficiently (eg addiction) to complicate the decision-making.

Loosely related to the topic, the current issue of The Economist has an interesting article here http://www.economist.com/businessfinance/displaystory.cfm?story_id=14031432

 

[digitlnoize]

Whopper, I agree with your post in general, and I love your idea of personal responsibility in particular. I am just afraid it never will be implemented to any significant extent for several reasons:

1) It is not going to be popular with the majority of voters.
2) The cost of running it will likely outweigh the potential savings (eg, seeking confirmation for provided info may be both awkward and expensive).
3) In many instances the concept of personal responsibility gets blurred sufficiently (eg addiction) to complicate the decision-making.

Loosely related to the topic, the current issue of The Economist has an interesting article here http://www.economist.com/businessfinance/displaystory.cfm?story_id=14031432

I know it would be difficult to implement in some instances, but for some of the more common problems (obesity, smoking, diabetes management) it could go a long way to helping the problem.

Obviously, as long as the patient was being proactive, with observed results, say 5-10lb weight loss since last visit or more well controlled diabetes...I don't see why some measures couldn't be implemented.

Of course, you're right. People won't like the idea. But, they also claim to not like dying, and this might help stop that...at least temporarily...

I just don't see why I should be paying for a lung transplant for a 75 pack year smoker who knows the dangers but doesn't even attempt to quit. I know that we're all paying for it now anyways, but I think you'd see many people quitting smoking if they knew that they'd have to pay for their own COPD care.

 

[whopper]

1) It is not going to be popular with the majority of voters.
2) The cost of running it will likely outweigh the potential savings (eg, seeking confirmation for provided info may be both awkward and expensive).
3) In many instances the concept of personal responsibility gets blurred sufficiently (eg addiction) to complicate the decision-making.

True.

My own opinion on it is the self incentive part would have to be made in a manner that people can grasp, understand and motivate for them to do it on their own.

E.g. tax deductions or no sales tax for gym membership, excercise equipment etc. No penalties for health problems beyond a person's ability to control (e.g. victim of car accident, assaults, genetic disorders), incentives for people who keep their BP, weight, cholesterol under control--whether or not they do so using medications. Just the act of compliance should mean something. More incentives for going to the doctor on regularly scheduled visits, doing the labwork, and following a doctor's advice (with full ability to seek other doctor's advice if you disagree).

More use of PAs, Nurse Practitioners, nurses, & nutritionists to help with patient education, in addition to doctors. E.g. the doctor diagnoses & treats, while other people in the treatment team can then sit with the patient, explain what the disorder is, and the important things the patient can do on their own to maintain their health long term.

Use of substances of abuse other than alcohol in moderation will worsen the person's point rating. Arrests, a (+) UDS, etc will worsen the person's points.

As for end of life options, a deduction for those who plan ahead on their end of life options, and actually do some educational work on their own to understand the realities of hospice care vs unrealistic interventions that will only extend life a few hours at a cost of thousands to hundreds of thousands of $$ a day. No penalty on what the person's decision is--the point is education and preplanning, not making them decide one way or the other.

IMHO, it can be easily broken into a point system kinda like NJ does for car insurance. Have a 1-6 point system, 1=best 6=worst. Best=regularly visits doctor, keeps weight, cholesterol & BP (or perhaps also blood sugar) under control, not abusing substances of abuse, does the standard of care in terms of proper screening (e.g. colonoscopy at age 50), and has a preplanned decision course on what to do in end of life scenarios.

IMHO its not hard for a patient to do these guidelines.

6=does not visit the doctor, smokes tobacco, had a (+) UDS for cocaine use, has high cholesterol, but does nothing about it, has no end of life options preplanned.

 

[lilnoelle]

And what is the penalty/reward going to be in the point system?

 

[digitlnoize]

All good ideas. The problem is that NO ONE is even talking about any type of patient accountability in the new system. At least, not that I've heard of.

It's simply: EVERYONE GETS COVERED.

I have a problem with that. Unfortunately, it seems that NO ONE else, republican or democrat, does. Mark my words, if we pass universal healthcare in america without a stipulation of this type, we're going to see our population get fatter, lazier, and even MORE unhealthy than we already are.

There are many ways to do it. I was going to make them pay a higher premium to the government insurance option if they fail to follow said guidelines, but tax credits or whatever works too...probably better...positive reinforcement, right?

 

[masterofmonkeys]

What's the most basic way of reducing the cost of healthcare?

Reducing demand. And that's sadly missing from this debate. In fact, the fact that its missing makes me wonder about the future of our society.

'preventive medicine' is still healthcare. Taking care of yourself is not.

What's the cost of spending an hour in the gym 4 times a week? Not much. A decent gym membership shouldn't cost more than around 250 bucks for a single individual (lower if you sign up as a couple or family).

What's the cost of one year of a moderate dose of lipitor? Around 1000 bucks.

Getting 3-5 hrs of exercise is twice as effective (in real terms) as lipitor in preventing heart attacks and stroke, even for such light 'exercise' as yoga, walking, etc. In dollar terms, it is 8 times as effective.

And while statins may have a modest benefit in dementia (not as large a reduction as for exercise though), they don't decrease your risk of diabetes (exercise does though), cancer (they may even increase it), debilitating osteoarthritis, etc, etc, etc.

Want me to go through this exercise for any number of ailments? Because I can. Even a moderately healthy lifestyle (light exercise 3-5 hrs a week, getting SOME healthy foods into your body, and eating a sane number of calories) can prevent, or at least reduce the severity and economic impact of 7 or 8 of the top 10 most expensive health conditions.

Those who are diligent about such things enjoy a huge advantage in QALY compared to those that don't, not to mention a gigantic difference in healthcare expenditures. For their pains, they get rewarded by subsidizing the unhealthy behaviors of others.

Sure, eating healthy costs more, but do you really mean to tell me that after adjusting for the actual benefits (i.e. better health) that it costs more to eat healthy--and enjoy the benefits of not developing diabetes by 35--than it does to eat crap food, along with all the health costs that go along with it?

Blah

 

[billypilgrim37]

If the prospect of having COPD isn't enough of a incentive to change behavior, then the prospect of having to pay for COPD care isn't going to be a strong enough incentive to change behavior either.

 

[OldPsychDoc]

There are no easy answers.

The main point is: healthcare costs money. There are only three basic sources of that money--a) cash from your pocket; b) insurance premiums paid by your employer if you're lucky enough to have a job with an employer able to pay them; or c) government via your taxes. Since b) ultimately entails taking lower wages in exchange for insurance benefits (a point that is often lost in this debate), you might notice that, basically, the cost always comes back to us. So the question is--how much are you willing to pay, either through increased taxes, or reduced wages, or reduced benefits, or direct cash outlay, for the care you receive?

A second point is this: illness isn't "fair". Even people living exemplary lifestyles get sick and injured. As much as we try to emphasize prevention, nothing short of absolute totalitarianism is going to get everyone to an ideal BMI. As billypilgrim said, no one WANTS COPD, or diabetes, or cancer. But no one is talking about banning smoking entirely, or bulldozing fast food restaurants to plant broccoli farms, etc. And I KNOW how to promote my health. My insurance plan will even give me a $20/mo rebate if I use my Y membership 12 times a month--but I struggle to make it twice a week. Would I be more likely to do it if the rebate were $200? Maybe. But I could still end up getting in a car accident and needing to go to the ER and OR and ICU and rehab and costing the plan a gazillion dollars that I honestly can't pay all by myself. I also can't help thinking about my patient last year who had quit smoking 15 years ago, but still got lung cancer and died within 6 months...

I'm also worried about how blame for illness gets attributed in these "health incentive" proposals. First off--to single out our discipline, who is to "blame" for a patient's schizophrenia, or depression, or PTSD? How does one prevent those things? Should my patient's catatonia be covered if we don't know why he got it, but if it were "proven" to be a sequela of his past methamphetamine use, well sorry J___, you don't get treated? I also SEVERELY dislike the tone that blames "those fat, smoking welfare patients" for their poor health while essentially excusing fat, smoking Grandpa Jim for his. It's always easier to blame "those" people, while forgetting that "those people" are just as important to their grandkids as Grandpa Jim is to his. (Grandpa Jim could ultimately be more culpable, as he maybe had the advantage of being able to drive himself to the grocery store to purchase fresh fruits and vegetables--yet chose not to--whereas "those welfare people" are stuck in an inner city neighborhood without a decent grocery store, and need to take two bus transfers to reach that supermarket. That's reality, folks. )

So here's what I think. We've got to do something. Healthcare costs are a serious drag on our economy--and that's not going to get any easier. American business will not be able to compete in a world marketplace where our competitors don't have the major business expense of employee health care. Healthcare is also important enough to society as a whole (and especially devastating and detrimental in its absence) that it requires the cost to be shared and spread across society as a whole. Right now I feel like we're sitting on the Titanic--with democrats trying to apply a big roll of duct tape to the hull, and republicans arguing about which lifeboat is going to win a rowing regatta....

Well now I'm depressed. I'm going to bed....

 

[digitlnoize]

If the prospect of having COPD isn't enough of a incentive to change behavior, then the prospect of having to pay for COPD care isn't going to be a strong enough incentive to change behavior either.

I don't know...I think you'd be surprised what a little money will do. I can't tell you how many people I've known that quit smoking recently due to the cig tax increase...

 

[billypilgrim37]

I don't know...I think you'd be surprised what a little money will do. I can't tell you how many people I've known that quit smoking recently due to the cig tax increase...

Don't worry, I'm a firm fan of the Pigou Club, and think sin taxes are very good policy. Taxing externalities makes sense, and there is clear evidence for it. That is very different than the above thread.

 

[Therapist4Chnge]

I believe it was MA that tried an incentive based program that would lower premiums for people who actively used the gym, etc.....and I believe it worked. I'm not sure of scalability, feasibility, etc.....but that was a bit of good news.

I am most concerned that all of the current plans encourage a welfare state with no accountability and a huge bill that will come due for most/all of America.

 

[digitlnoize]

I believe it was MA that tried an incentive based program that would lower premiums for people who actively used the gym, etc.....and I believe it worked. I'm not sure of scalability, feasibility, etc.....but that was a bit of good news.

I am most concerned that all of the current plans encourage a welfare state with no accountability and a huge bill that will come due for most/all of America.

It might be difficult, but some type of accountability could be implemented. Lower premiums if you use the gym, or lose weight, or attend a smoking cessation program. Nothing complicated, but a few, smart control measures wouldn't be that hard.

Obviously, we can't penalize people for accidents, or for true medical problems, as mentioned above.

However, I believe that if you're 200lb overweight, and you lose weight, you should be rewarded for that effort. Alternately, if you're 200lb overweight because you eat every meal at Outback Steakhouse (mmmm...) and you refuse to follow your doctor's advice and stop, the american people shouldn't be paying for your care...you should.

 

[whopper]

If the prospect of having COPD isn't enough of a incentive to change behavior, then the prospect of having to pay for COPD care isn't going to be a strong enough incentive to change behavior either.

I don't think that'll be true of everyone, though it is true for several. Sometimes people need more short term goals laid out to them because denial & youth make people not worry about the effects of what they do in the here & now. Such an incentive based plan could give people better directives.

However if your bottom line is true--then fine so be it. If people don't want to stop smoking and paying more in cigarettes & higher health insurance doesn't deter them, let them do it---and let them pay for it so those who don't smoke don't have to pay for it.

Healthcare is communal. If someone pees in the communal well, I shouldn't have to drink their pee.

Obviously, we can't penalize people for accidents, or for true medical problems, as mentioned above.

Very much agree. Such a system has to follow ethical guidelines. Justice is one of them. People who have health problems they could not avoid with responsible behavior such as genetic defects, getting hit by a drunk driver, etc should not be penalized.

My insurance plan will even give me a $20/mo rebate if I use my Y membership 12 times a month--but I struggle to make it twice a week

And that's great that your insurance does that, however incentive based programs in health insurance are rarely utilized, and several in the public do not know they exist.

I'm also worried about how blame for illness gets attributed in these "health incentive" proposals. First off--to single out our discipline, who is to "blame" for a patient's schizophrenia, or depression, or PTSD?

Schizophrenia does not have much data that allows the person that suffers from it to have been able to avoid it--therefore it should not be considered a disorder that's avoidable with responsible self care. There is some data, but its weak, and not part of the standard of care to implement.
Same with PTSD, the person suffering from it is the victim of accidental dangerous sitautions or the direct assault of others. Depression too is not something where there's an active standard to prevent it when one has never had it before. However substance abuse does have enough data to show there's a standard--don't use it in the first place and high schools across the country have active programs to tell people not to abuse drugs.

As for healthcare providers passing judgment, and would this sytem encourage judgment? IMHO I don't think so. We already know the person's history & SES while we treat them because we're supposed to obtain them. I wouldn't care what insurance point system they have, I still have to treat them, just like now, I still got to treat the cocaine users I see at that special time of the month where they no longer have enough money to pay for food because they spent it on cocaine, and now they want hospitalization to get free food at a cost of $1500/day to the taxpayer.

The point system for car insurance does encourage people to drive safely. The credit rating system does encourage people to handle their finances responsibly. We too should have a system that takes away much of the financial burden for those willing to take responsibility over their own health, as well as make those who can afford pay more if they do not choose to take charge of their health.

Whether we like it or not-healthcare is communal. Those that take away from the communal store more should pay more. Eating excessive amounts was something that since the beginning of human society, up until 3 2 decades ago was something only the rich could afford. Given that our healthcare system & economy are in shambles, we are not yet to a point where we can afford unlimited health interventions for everybody. It is unfair to make those who are responsible pay for the preventable mistakes of others.

 

[digitlnoize]

Healthcare is communal. If someone pees in the communal well, I shouldn't have to drink their pee.

nice.

As much as I love this discussion, we are a little off track...I'd still like to hear more peoples' opinions on how this reform might affect psych.

I just read through the Senate plan. Lots of stuff about medical homes. How do you guys think the medical home concept might affect your practice?

I only saw Peds mentioned specifically as a specialty getting it's own extra funding (including $$$ for child/adolescent fellowships).

 

[digitlnoize]

My insurance plan will even give me a $20/mo rebate if I use my Y membership 12 times a month--but I struggle to make it twice a week. Would I be more likely to do it if the rebate were $200? Maybe.

I think these types of incentive plans are great. The problem lies in the numbers. I wouldn't go to the Y 12x/mo for $20 either. Would you?

How about 4x/mo for $25? $50?

The answer lies in finding how much lazy people want to be paid for exercising.

Some people will always see exercise as "work" and not want to do it. A financial incentive might get them off their *****. And, although it would cost money, I think the benefits you'd see from a healthier, more active society would far outweight the initial financial outlay.

Sorry...I'm still off-topic a bit myself. I'll shut up now, and return to psych land...so, how will reform affect you guys?

 

[whopper]

Well, I'm no expert of Obama care but an APsychiatricA PAC person called me yesterday asking me to donate $365 claiming that Obama's plan would dramatically cut funding to treat PTSD. That's something I'd be against.

Now I don't know the specifics of the plan but this APA person really presented it as if it would reduce PTSD funding.

I wouldn't go to the Y 12x/mo for $20 either. Would you?

I don't go to the gym, I use P-90X. Such a system IMHO would have to be like an Apple Computer product. It has to be easy to understand & implement. Gyms could for example mail out the information of membership to the insurance company instead of leaving it to the consumer. Or it could be based on a simple point system like I said-and the person just had to keep their weight, BP, cholesterol under control, and visit the doctor on regularly scheduled visits, and follow the doctor's advice with full ability to seek a second opinion without penalty if the person disagrees with the doctor's advice.

 

[OldPsychDoc]

... However substance abuse does have enough data to show there's a standard--don't use it in the first place and high schools across the country have active programs to tell people not to abuse drugs..

And we know how well THAT works... 🙄

So we're going to tell folks--"Sorry, you didn't listen in high school, so this treatment program that you're already ambivalent about is coming out of your own pocket?"

It really sounds like some of these point/incentive systems will INcrease, not decrease bureaucracy--to say nothing of the need for litigation/mediation/arbitration to figure out if payment is being justly/unjustly applied. And administration costs? For example, someone suggested that the gym would notify the insurance company of how often the consumer exercises... Perhaps the extra hiring of clerical workers for this will lift us out of the recession after all!

Also, if we are risk-stratifying people -- doesn't this take us right back to the "pre-existing condition" problem?
And wouldn't this allow insurance plans to justify an exorbitant premium for a schizophrenic (well beyond their ability to pay, given the reduced earning power) based on their higher morbidity due to med side-effects? Talk about your Catch 22! You can ding them for non-compliance psychiatrically, or ding them for compliance medically!

 

[OldPsychDoc]

...
Healthcare is communal. If someone pees in the communal well, I shouldn't have to drink their pee.....
Whether we like it or not-healthcare is communal. Those that take away from the communal store more should pay more. Eating excessive amounts was something that since the beginning of human society, up until 3 2 decades ago was something only the rich could afford. Given that our healthcare system & economy are in shambles, we are not yet to a point where we can afford unlimited health interventions for everybody. It is unfair to make those who are responsible pay for the preventable mistakes of others.

Like it or not, this is already happening. The premiums you pay (or paid on your behalf) are probably more than the benefit you receive. Your hospital has to "eat the cost" of a certain amount of charity care. Your taxes pay for those who cannot afford health care on their own. And rationing does happen--either via access to the system, or via private and public insurers placing limits on benefits...

 

[digitlnoize]

Like it or not, this is already happening. The premiums you pay (or paid on your behalf) are probably more than the benefit you receive. Your hospital has to "eat the cost" of a certain amount of charity care. Your taxes pay for those who cannot afford health care on their own. And rationing does happen--either via access to the system, or via private and public insurers placing limits on benefits...

Exactly, and this is what we need to stop if we expect patients to take some responsibility for their own health.

 

[digitlnoize]

And we know how well THAT works... 🙄

So we're going to tell folks--"Sorry, you didn't listen in high school, so this treatment program that you're already ambivalent about is coming out of your own pocket?"

It really sounds like some of these point/incentive systems will INcrease, not decrease bureaucracy--to say nothing of the need for litigation/mediation/arbitration to figure out if payment is being justly/unjustly applied. And administration costs? For example, someone suggested that the gym would notify the insurance company of how often the consumer exercises... Perhaps the extra hiring of clerical workers for this will lift us out of the recession after all!

This is the 21st century. All it takes is an ID badge and a crappy computer connected to the internet. I walk into the gym, swipe my badge, and *ding*, it registers on my EMR that pt #24601 went to the gym on 7/17/09 at 10am. No bureaucracy. The physician simply looks at the EMR and notes how often the pt is going to the gym. He also notes the patients weight loss and asks about their diet. If the patient has NOT been going to the gym, has gained 20lbs and has not changed their diet, it get coded as a #xxxxxB instead of #xxxxxA. Obviously xxxxxB costs more for the patient.

Seems pretty simple to me.

Let me stress again, that I'm not advocating this for all diseases across the board. I don't even think I'd go as far as including ANY psych diseases, unless you count cigarette addiction.

I'm talking about KEY public health issues. Obesity, Smoking, Diabetes. These are things that are leading killers in our society, AND have been shown to be easily managed by patients.

I mean, what % of the population is obese? What percent is schizo? What percent is addicted to heroin? I agree that mental health and drug addiction are important issues, but I'm not really advocating that we address those things in this manner. I'm talking here about attacking the MAJOR public health issues head on.

We're not going to see a drop in obesity levels (and thus all the diseases it causes) until we get patients to take some accountability for their own health. And THAT won't happen without some serious incentives. We like our McDonald's and Ben & Jerry's too much!

 

[Therapist4Chnge]

I think some re-allocation of funds could provide some longer-term benefits....even with a broken system.

1. Implement a premium reduction for smoking cessation, gym usage, etc.
2. Invest in more preventative care / outreach education
3. "Group" buys for insurance, across small companies
4. Provide some low/no-cost medical services in areas with higher ER use/abuse. The amount $ hospitals have to eat in the ER is obscene.

 

[billypilgrim37]

This is the 21st century. All it takes is an ID badge and a crappy computer connected to the internet. I walk into the gym, swipe my badge, and *ding*, it registers on my EMR that pt #24601 went to the gym on 7/17/09 at 10am.

And #24602 swipes in and heads to the breakroom, where he stares at women in workout clothes for three hours while drinking four mountain dews, and then heads home!

And #24603 heads to another "gym" that opens up down the street with nothing but a few dodgeballs and some pinball machines and a smoking lounge. But hey, cheap insurance!

And businesses put a few treadmills in the basement behind a few filing cabinets with a card swipe, and everybody makes sure and swipes their card in and out as they come back and forth from their smoke breaks.

And don't tell me these would be the exceptions, not the rule. 😉

 

[OldPsychDoc]

I think some re-allocation of funds could provide some longer-term benefits....even with a broken system.

1. Implement a premium reduction for smoking cessation, gym usage, etc.
2. Invest in more preventative care / outreach education
3. "Group" buys for insurance, across small companies
4. Provide some low/no-cost medical services in areas with higher ER use/abuse. The amount $ hospitals have to eat in the ER is obscene.

Something like this, perhaps?

Disclaimer: I am a member and employee of one of the featured organizations. And happy on both counts!

 

[Therapist4Chnge]

Something like this, perhaps?

Disclaimer: I am a member and employee of one of the featured organizations. And happy on both counts!

👍

ps. It wouldn't be an article without some Cato input. 😀

 

[digitlnoize]

And #24602 swipes in and heads to the breakroom, where he stares at women in workout clothes for three hours while drinking four mountain dews, and then heads home!

And #24603 heads to another "gym" that opens up down the street with nothing but a few dodgeballs and some pinball machines and a smoking lounge. But hey, cheap insurance!

And businesses put a few treadmills in the basement behind a few filing cabinets with a card swipe, and everybody makes sure and swipes their card in and out as they come back and forth from their smoke breaks.

And don't tell me these would be the exceptions, not the rule. 😉

This is why the physician must be the one monitoring the patient's health. If they say they are exercising, but they haven't lost weight, yet all their tests are normal...that's a red flag that they may be abusing the system.

Obviously, there'd have to be some licensing of the gyms at the state or city/county level to prevent the sham gyms.

Worst case, you'd need a small organization, similar to the Joint Commission (or state ABC regulators) to police the gyms and companies for wrongdoing.

Again, I'm not saying there aren't problems that need to be worked out, but compared to a TOTAL overhaul of the system, it's certainly doable, and if you consider the benefits...

Or, we could just not do it 'cause it's hard. That's fine too...

 

[billypilgrim37]

Again, I'm not saying there aren't problems that need to be worked out, but compared to a TOTAL overhaul of the system, it's certainly doable, and if you consider the benefits...

Those two things have nearly nothing to do with each other.

 

[digitlnoize]

Those two things have nearly nothing to do with each other.

Which two things? The problems, the overhaul, or the benefits?

 

[OldPsychDoc]

And #24602 swipes in and heads to the breakroom, where he stares at women in workout clothes for three hours while drinking four mountain dews, and then heads home!

And #24603 heads to another "gym" that opens up down the street with nothing but a few dodgeballs and some pinball machines and a smoking lounge. But hey, cheap insurance!

And businesses put a few treadmills in the basement behind a few filing cabinets with a card swipe, and everybody makes sure and swipes their card in and out as they come back and forth from their smoke breaks.

And don't tell me these would be the exceptions, not the rule. 😉

billy, billy, billy....where is your faith in the goodness of human nature?
🙄

 

[whopper]

And we know how well THAT works...

So we're going to tell folks--"Sorry, you didn't listen in high school, so this treatment program that you're already ambivalent about is coming out of your own pocket?"

Hey, like I said about those that choose not to stop smoking, if these people don't choose to stop abusing drugs, then so be it --> they pay more for insurance. I'm not saying you pay out of your own pocket, I'm saying you pay more for insurance. Slapping a few hundred more dollars a year on a rate the person still can afford is not the same as paying out of pocket (when some programs are in the thousands of dollars--a day).

That IMHO is actually quite generous being that the extra money they are paying is probably not equal to the amount they are taking out. Incentives IMHO should be a buffer to encourage better responsibility, not a punishment system.

Part of getting substance abusers off abusing is for them to take personal responsibility, and realize the harm it causes to themselves & others. They also could earn getting to lower rates by attending substance abuse programs, having consistent clean urine drug screens, and working out a substance abuse treatment plan with their doctor.

 

[billypilgrim37]

Incentives IMHO should be a buffer to encourage better responsibility, not a punishment system.

Absolutely. But there are plenty of ways to create incentives to improve behavior that have nothing to do with health insurance.

Tax cigarettes. Tax soda. Tax fast food. Get rid of nonsensical farm subsidies that make it cheaper to grow fiber-one bars than wheat (heck, as a vegetarian, I think it's lousy that I subsidize your steaks with corn subsidies!). Tax alcohol. Legalize pot and tax it to death. Do things that make sense.

But for the love of God, quit punishing people for their health, good or bad. Anyone's who's taken an epidemiology course should understand the notion of attributable risk. And if you understand the notion of attributable risk, you understand why tying behavior to access to health insurance is bad policy.

Someone getting bankrupted because they lose their job after being diagnosed with cancer has nothing to do with whether people go to the gym or not. These topics, they have nothing to do with each other, no matter how much the Glenn Becks and other "I call myself a libertarian but I got a C in Econ 301" pundits want to make you think they do.

 

[OldPsychDoc]

👍

ps. It wouldn't be an article without some Cato input. 😀

The Cato guy says "His concern is that legislation will create a de facto government-run plan, essentially a national co-op run and subsidized by the federal government."

And I say "Maybe that's exactly what is needed!"--with the caveat that it be managed according to evidence-based guidelines and professional peer review.

 

[billypilgrim37]

😉

billy, billy, billy....where is your faith in the goodness of human nature?
🙄

I left it under the desk in the psych emergency room. 😉

 

[Anasazi23]

I'm really not knowledgable enough to pretend I have a plan that works for everyone. All I know is, the current system doesn't work, and neither will the one that's (likely) coming.

I'm against any bill that doesn't include sweeping malpractice reform. This bill contains none.

My understanding is that the bill will fail, for at least two reasons:

There are enough blue dog democrats who see this as irresponsible spending and will vote against it.

There are far left pundits who see this as not sweeping enough, and will vote against it.

Combine this with the republicans, which will virtually all vote against this, and it looks like it could be DOA.

We'll see, but I doubt this will get pushed through before August, as Obama 'hopes.'

 

[billypilgrim37]

As a👎 (ir)relevant side note that doesn't necessarily deserve its own thread, check this out.

 

[digitlnoize]

As a👎 (ir)relevant side note that doesn't necessarily deserve its own thread, check this out.

That very interesting, I hadn't actually read up on her yet...

I myself am a bit overweight (~20lbs). It's something I'm working on. As a non-traditional student (31yo), I came to the medical world a bit late in life. I was raised in a house that did little to no real cooking, ate out alot, and ate lots of crap.

I'm not trying to make excuses for myself, I know I'm a bit on the tubby side. However, I didn't really understand how to fix that until I began pursuing medicine, and not really until more recently, as I've learned more about nutrition, etc. I am trying to illustrate that doctors can be overweight for reasons other than being hypocrites.

That being said, I don't want my patients looking at me like "you're one to talk" when I ask them to diet. And, honestly, I don't expect everyone to reach their ideal weight...but I'd hope I can convince the to at least not be morbidly obese...

So I'm working on my weight. I'm eating better. Much more veggies (which I never ate growing up), more fiber, less fast food, less soda. I'm exercising 3-4 times a week now...it's certainly been helping. I'm hoping I can be closer to my ideal weight by this time next year!

My point is, that weight is a struggle. Perhaps our new surgeon general hasn't been a doc for that long. I doubt it. Perhaps she has a thyroid problem, or another condition we don't know about. Maybe she just LOVES chicken wings! Whatever the case, I doubt it would make much of an impact. I've never seen any surgeon general before now...it's not like they are on TV every day...lol. They don't have their picture on those cigarette warnings.

 

[OldPsychDoc]

As a👎 (ir)relevant side note that doesn't necessarily deserve its own thread, check this out.

I'm guessing that Art Kaplan is just ticked that either
a) Sanjay Gupta said "No" to Obama's nomination; or
b) he didn't get asked!

 

[surftheiop]

Back to one of the original questions.


what sort of effects would the health plans currently being discussed have on psychiatrists?

would they get hit with the "specialist" hammer or would they get a "primary care" boost?

 

[OldPsychDoc]

Back to one of the original questions.


what sort of effects would the health plans currently being discussed have on psychiatrists?

would they get hit with the "specialist" hammer or would they get a "primary care" boost?

We don't seem to fit in either category right now. The specialists who will really take hits are the more procedurally oriented ones. The demand for mental health services being what it is, and with the recent passing of parity, I'm thinking that we're going to stay just about where we are...

 

[masterofmonkeys]

Don't worry, I'm a firm fan of the Pigou Club, and think sin taxes are very good policy. Taxing externalities makes sense, and there is clear evidence for it. That is very different than the above thread.

I have about 2 alcohol drinks per month (scotch, guiness, or wine for preference). By almost all accounts it would be beneficial to my health if I drank about 28 more than I currently do. Increasing the tax on alcohol would be detrimental to my health.

 

[billypilgrim37]

I have about 2 alcohol drinks per month (scotch, guiness, or wine for preference). By almost all accounts it would be beneficial to my health if I drank about 28 more than I currently do. Increasing the tax on alcohol would be detrimental to my health.

For a monkey, I'll buy the first round, and for the master, I'll buy the second. Only 26 more to figure out! 😉

I've tried to actually think of ways to inversely tax alcohol. I'm pretty sure Natural Light has done a lot more damage to the country's health than Guinness, which is of course partially related to cost, but also somewhat independently to the sort of folks who drink "better" (for lack of a better term) beer. I can afford to spend 40 bucks on a case of Oberon, because it will last my wife and I the whole summer with friends coming over a few times. If I was one of my patients, for whom a football game is accompanied with an entire case of Rolling Rock, it'd be a different story.

 

[Poitiers2]

Don't worry, I'm a firm fan of the Pigou Club, and think sin taxes are very good policy. Taxing externalities makes sense, and there is clear evidence for it. That is very different than the above thread.

I can in part agree with you. Until some Washington beurocrat attempts to start taxing people for not driving a car small enough to ensure your immediate death in a fender bender on the very questionable science of global warming and the even more questionable science of man's effects on global warming.

There's no doubt taxes on things like cigarettes work. To a point. Until enough people quit so quickly that Washington or the states have budget shortfalls and have to go after something else....

Consider me a vary wary consumer of any tax...more often than not, it's going towards wasteful spending. Government fails on efficiency every time.

 

[billypilgrim37]

There's no doubt taxes on things like cigarettes work. To a point. Until enough people quit so quickly that Washington or the states have budget shortfalls and have to go after something else....

Consider me a vary wary consumer of any tax...more often than not, it's going towards wasteful spending. Government fails on efficiency every time.

The point of these taxes on externalities are not necessarily to generate revenue, but to change negative behaviors. The fact that they generate revenue is just a bonus. If the government decided to take all of its money from cigarette taxes into a field and burned it every year, there would still be net good on public health. As long as the dirty money didn't produce so many pollutants into the atmosphere. 😉

I'd suggest starting to read Greg Mankiw's blog. Mankiw was Romney's top campaign econ adviser, and did work for W as well. Not exactly a liberal. Being a "wary consumer of any tax" isn't particularly a defensible position for someone who even casually follows the economics literature, even with a firm conservative bias.

Similarly, Marginal Revolution is a libertarian slanted site you really need to be reading if you're going to have any opinion about any sort of economics policy.

 

[masterofmonkeys]

A long comprehensive piece I wrote one insomnia-filled night about the healthcare issue:
http://www.facebook.com/home.php#/profile.php?id=401772&v=app_2347471856

A very different take than most of what we see.

Neither national health insurance, nor are peculiar employer-coupled and risk-insulated system are particularly sustainable.

But it also seems to me that forcing those who choose to live healthily to pay the tab of those who don't is extremely unjust.

And if people cannot be asked to be the stewards it raises an interesting philosophical question: If you can't even be trusted to take care of yourself, how can you be trusted with a vote in determining how our country is governed?

 

[OldPsychDoc]

A long comprehensive piece I wrote one insomnia-filled night about the healthcare issue:
http://www.facebook.com/home.php#/profile.php?id=401772&v=app_2347471856

A very different take than most of what we see.

Neither national health insurance, nor are peculiar employer-coupled and risk-insulated system are particularly sustainable.

But it also seems to me that forcing those who choose to live healthily to pay the tab of those who don't is extremely unjust.

And if people cannot be asked to be the stewards it raises an interesting philosophical question: If you can't even be trusted to take care of yourself, how can you be trusted with a vote in determining how our country is governed?

Perhaps we should return to property ownership as a requirement for voting rights?

 

[masterofmonkeys]

Perhaps we should return to property ownership as a requirement for voting rights?

funny. Thats why I said it was a philosophical and not a practical question.

We are sitting here discussing all the reasons that people know better but don't behave in a healthier fashion. This is the long-term planning of the thing most important to a person: themself. And if someone lacks the ability to engage in long-term planning in their own life, what does that say for their ability to do so for an entire country?

I think it's a valid question. Dubious practicality sure. But worrisome and intellectually stimulating nonetheless.

 

[billypilgrim37]

I think it's a valid question. Dubious practicality sure. But worrisome and intellectually stimulating nonetheless.

If that's what you find intellectually stimulating, I'm gonna have to buy you more than just two rounds! 😀

 

[digitlnoize]

Perhaps we should return to property ownership as a requirement for voting rights?

I don't care about property ownership, but how about a Civics test or something...If you can't pick the 3 branches of government from 4 choices, you can't vote.