The Audacity of Greed: Profiteering in American Medicine

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With the advancements in medical science and technology, why do Americans still suffer the brunt of an ineffective health care system? The patient is not the priority in today's medical world. The Doctor is not heeding the Hippocratic Oath --- but instead is motivated by money. Medical profiteering has driven medical costs to unsustainable levels while eroding the quality of care.

Russell Andrews' book Too Big to Succeed: Profiteering in American Medicine   provides an interesting analysis of this trend. He reveals the rotten core of health care system hidden from outsiders. Discover why health care costs are increasing while medical benefits are dwindling.

Problems arise when there is a mismatch between reality and our perception of reality. In the scientific world, there are paradigms that guide the pursuit of knowledge. Experiments are constructed based on rules (guidelines based on prior experiences) to further support or disprove those paradigms. Based on how ingrained a paradigm is (“Is it based on fact or on ideology?”), changing the paradigm can be very difficult. Examples of paradigm shifts from the scientific world include the shift from “the earth is flat” to “the earth is round” and the shift from “the earth is the center of the solar system” to “the sun is the center of the solar system.” People have paid dearly for their correct but unpopular point of view (e.g., Galileo was placed under house arrest for insisting that the sun, not the earth, was the center of the solar system). Scientific paradigms may not shift easily, as documented by Thomas Kuhn in The Structure of Scientific Revolutions.1

Similar problems arise in the socioeconomic world when there is a mismatch between reality and our perception of reality. Here there is not only ideology that may hinder acceptance of the mismatch, but also one’s perception of his or her own personal economic benefit. In the game of life, societal good rarely trumps personal gain (or, perhaps more accurately, one’s perception of personal gain). This appears The current health-care system in the United States has a significant mismatch between the reality of the health care provided to the populace as a whole and the perception of that reality—at least the perception in the minds of many people in this country.

Though we spend 50% more on health care per capita than other developed countries, a multitude of measures—such as life expectancy and infant mortality—indicate that we in the United States are not getting health-care value for our money. Yet many argue, often with religious fervor, against change in our health-care system. One must have “choice” (more accurately, perceived choice rather than actual choice) not “socialized medicine” (whatever “socialized medicine” means) at all costs—even if adequate health care becomes a dream for the majority of Americans because of the phenomenal personal expense. When an industiy constitutes upward of one-fifth

Medicine today in the United States is big business. To see how far it has deviated from its origins in the Western tradition, we do well to consider the Hippocratic Oath:

Understand how we can change the trend in doctor-patient relationships all over the country, where individuals can start to realize that great emphasis should be placed on “the healing art and science of medicine,” instead of on the profitability of the health care delivery system.

We need to learn how the profit has trumped the patient in American medicine, and fight back.  Profit is now the most imporant agent of change for real health care in America, which corrupts the whole system. We need to know the typical pitfalls and fight against them. In the US medical system the patient life is often depends on how well he/she understand the ropes. Yes, your life depends on it! It is very early to gat expensive and unnecessary surgery in the USA those days. Which can be deadly. The number of  cardiologists sentenced to jail in the USA is in dozens. And they are just the tip of the iceberg. Cardiatic stents are probably the most glaring example. But other "lucrative" areas, in such field as gastroenterology exists too.  Another huge area is pharmacology abuse ("big-pharma" corrupting influence).

Dave Zweifel, The Capital Times (Madison, WI)

Here's another one to remember when someone tells you that our "private" health care system works: The Wall Street Journal ran a front-page story last week with the headline that said it all: "As Patients, Doctors Feel Pinch, Insurer's CEO Makes a Billion." The story, datelined Minnetonka, Minn., was about William McGuire, a doctor who stopped practicing in 1986 to take a management job with UnitedHealth Group Inc., one of the largest HMOs in the country.

He's now the chief executive officer of the corporation, makes $8 million a year in salary plus bonus, has personal use of the company's private jet and has amassed what the Journal describes as "one of the largest stock options fortunes of all time." According to the newspaper, those options total $1.6 billion.

"Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines Corp.'s Louis Gerstner never were granted so much during their time at the top," the WSJ story said.

But the gist of the story is that while McGuire and other UnitedHealth execs are raking in millions, their company is putting the squeeze on everyone else.

"Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying health care system," the bible of the business world reported. "Many of them aren't discovering drugs or treating patients. They're middlemen who process the paperwork, fill the pill bottles and otherwise connect the pieces of a $2 trillion industry."

The newspaper's research shows that UnitedHealth has particularly benefited in recent years as health care inflation eased somewhat.

Insurers still raised premiums at double-digit rates. At UnitedHealth, for example, its stock price tripled from January of 2003 to January of this year and its net income rose to $3.3 billion. Hence, the nice board-of-director-approved windfall for McGuire. (Interestingly, former UW-Madison Chancellor Donna Shalala is a member of UnitedHealth's board.)

"In Minnesota, such riches have infuriated some people," the story continued. "Joel Albers, a Minneapolis pharmacist, regularly impersonates Dr. McGuire at state fairs, donning a tuxedo, holding up an enlarged picture of Dr. McGuire on a stick and handing out leaflets denouncing corporate greed."

Of course, this is just one more anecdote that serves to describe our broken health care system, which leaves more than 40 million Americans without coverage and an embarrassment of riches for those who know how to milk that system.

On one hand we have Medicare, which provides universal single-payer coverage to all Americans over age 65 at about a 2 percent administrative cost. On the other hand we have a hodge-podge of plans with layer after administrative layer that gobbles up close to 20 percent in overhead costs (Dr. McGuire's just a piece of that) and leaves millions out in the cold.

How hard can it be to choose in which direction we need to go?

Dave Zweifel is editor of The Capital Times. E-mail: dzweifel@madison.com

Copyright 2006 The Capital Times

Source: The Capital Times (Madison, WI)
http://www.madison.com/tct/opinion/column/index.php?ntid=81491&ntpid=0

The HMOs and their managed care systems  ballooned from a headache to a plague

November 13, 2003 Home Doug Dowd Economic Historian by Doug Dowd

The HMOs and their managed care systems -- first supported in the Nixon years -- ballooned from a headache to a plague beginning about ten years ago. Their pitch was that they would end the inefficiencies of the past.  However, the period in which they have come to dominate the health care system is precisely that in which its costs -- and its inefficiency (unless you count mountains of paperwork something other than waste -- began the acceleration that continues.

Some of the rising costs were due to factors other than the HMOs, not least the gouging prices set by the pharmaceutical giants. OK, but all of them are part and parcel of the "for-profit health care system." Nonetheless, the HMOs have done at least their share in bringing about today's mountainous costs.

What started out as annual one-digit overall cost increases became two-digit as the 1980s ended, rising to 15.3 percent for 2002. Not good enough: In mid-2002 the NYT reported that "Health maintenance organizations are demanding rate increases of 22 percent in their ongoing negotiations with employers for 2003... which will be passed on to consumers." They were "passed on," and they continue to be.

As the tendency of always higher costs and prices continues, it needs repeating that the provision of health care to the average person has decreased both quantitatively and qualitatively. What's good for their profits is bad for our health.

What is it about the HMOs that such is the case? What was the system they presumed to replace with great savings to all, and profits to them as a reward? It was called the "fee-for-service" system: Other than those covered by Medicare and Medicaid, health insurance for those who had it was selected and paid by one's employer, which used to be so for about two-thirds of workers.

As the numbers of insured rose from the 1950s on, so did doctors' incomes: the insured could choose their own doctors and the doctors soon realized that the more treatments they gave the better off they -- but not necessarily their patients -- were. As Ellen Frank pointed out two years ago, "American doctors performed invasive tests and procedures at rates far exceeding international norms....Caesarean sections, surgerized ulcers, hysterectomies and tonsillectomies far above the rates in other countries, etc." (Dollars & Sense, 5/6, 2001)

Adding to that, past and present, is the friendly corruption between doctors and labs and drug companies. The pleasant consequence for doctors from 1960 to 1990 was that their incomes rose two to three times faster than the nation's, bringing them up to a lovely $200,000 annual average. So that's what the Hippocratic Oath was about!

One might think that such an evolution -- or, better, devolution -- would have led everyone but the doctors and labs and drug companies to open their minds to a national health service/single-payer system. But that overlooks certain large facts:

1) Employers as a whole tend to have a knee-jerk negative reaction against anything do with government (unless it is in the nature of a subsidy), and just as "instinctive" a response in favor of "private enterprise," which is what HMOs are;

2) the average citizen lives in the same society, and has been taught to think in much the same way, if not for the same reasons;

3) the major insurance companies have always been opposed to any form of social insurance -- beginning with their adamant fight against social security from 1935 to the present; and

4) this created a new industry for thousands of lobbyists. They have been very successful indeed in their efforts on behalf of the "Big Five" insurance companies (Aetna, Cigna, Metropolitan, Prudential and Travelers) and related managed care companies -- which, taken together, now "cover" 90+ percent of those receiving care. Here a lucid and crisp summary review of what brought us to our present state, and how it happened (as related by Ellen Frank):

The early 1990s saw a wave of mergers and acquisitions among health insurers that left large regions of the country with only two or three competing health plans. Their superior bargaining power allowed insurers to negotiate sharp reductions in fees, which were passed on to employers in the form of lower premiums. In 1994 the average health-insurance premium /paid by employers/ fell for the first time in years; premiums increased at or below the inflation rate for the rest of the 1990s.

Hospitals, facing lower reimbursement rates, cut staff and beds for traditional inpatient care while expanding facilities for expensive services like outpatient surgery. Still, hospitals throughout the country suffered operating losses. Large urban hospitals in low-income areas were especially hard-hit.../some like that of Los Angeles, closing entirely/. For-profit hospital chains moved in quickly, buying up scores of non-profit community hospitals.

So, with patients and providers (doctors, labs, and hospitals) getting the dirty end of the stick, that leaves the HMOs, drug companies, and top insurance companies getting the sweet end -- their owners, their CEOs and their countless lobbyists, that is.

Business being business, another rising tendency is that of HMOs dropping Medicare patients, more than 2.5 million 1998 to the present. Plus, "Medicare patients can expect 'major changes -- that is, reductions of -- benefits, even if they are still enrolled: cutbacks in drug coverage /already cruelly inadequate/, and increases in premiums and co-payments." (ibid.)

So there we are. Or are we? Although there is a rising tide of anger, frustration, and worry among our people at the costs of medical care in the USA, with some emerging movement toward universal coverage, most still see the U.S. system, though costly, as the best.

The best is none too good: "According to a recent study of the Institute of Medicine, medical errors in hospitals kill up to 98,000 patients yearly, while injuring perhaps a million more." (Washington Post, Editorial, "America's medical scandal," 12-10-02). Such deaths and injuries are called "iatrogenic"; that is, caused by the docs themselves.

That was a few years ago. Now, as the USA's entire health care system becomes always more privatized and always more expensive to those needing it, those years are coming to look like paradise lost; and we ain't seen nothin' yet.


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Old News ;-)

[Feb 22, 2019] How Stupid Do They Think We Are - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

Notable quotes:
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
Feb 22, 2019 | www.nakedcapitalism.com

How Stupid Do They Think We Are? – Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo Posted on February 22, 2019 by Yves Smith By Roy Poses , MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

In the early 21st century, the debate about health care reform in the US ramped up. The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients. Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare. Arguably, Obamacare ended up damaged but not repealed. Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect. (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US. Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense.

Dark Money to Defend Commercial Health Insurance

We already discussed how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats. They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board. We listed 10 such members in 2015. It also historically has received financial support from some corporations. We listed 17 in 2018.

Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All." The Hill stated its

members include major industry players such as America's Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America

So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible. Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new. What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies. Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison)

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

' Most people don't understand the basics of health-care economics in the United States ,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland .

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him. Thus, he began with an implied logical fallacy, the appeal to authority .

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred. $3.5 trillion? Health care costs paid by employers and employees?

The context of his use of that phrase did not help. Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS) . However, that was total health spending, not just the amount spent by Medicare and Medicaid. Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees. While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.

Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point. So in formal terms, he used the logical fallacy of an argument by gibberish .

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. ' I don't think [corporations and employees] can afford to provide that access as described.'

However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described." So this appeared to be an example of the logical fallacy of the non-sequitur .

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News . So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate. One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy.

First, from t he New York Times, January 29, 2019 :

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You're talking about trillions of dollars ,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation's first primary in 2020.

'I think you can have 'Medicare for all' for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time .'

Second, from CNN on January 30, 2019 :

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. ' It's unaffordable .'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much. Yet neither addressed how much our current health care system costs. However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system -- and that journalists almost never do when they're asking questions. You have to compare what a universal system would cost to what we're paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That's a lot of money. But you can't understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we'll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years -- which every universal plan does -- you can't say it's 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison .

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen -- whose understanding of investments, costs and benefits helped them become billionaires -- can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they're not biases at all but are instead inescapable rationality.

Maybe. However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda ") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

' That's not correct. That's not American ,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised. Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition .

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry. But that is for another day .

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money. We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.

It is hard to believe that the defenders of the current system are not mostly self-interested. That status quo has made some people very rich.

It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote ,

Wendell Potter, author of Deadly Spin , has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers. He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering. He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work. Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal. Still, however, their arguments are ultimately built on sand.

As I did in 2011 , it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake , from climate change to defense policy.
[Potter, Huffington Post]

So,

The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical .
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.


Disturbed Voter , February 22, 2019 at 4:26 am

Can any system of incentives work, for both the patients and the care providers? The tendency is for patients to seek professional help over over-the-counter remedies when it is unnecessary (hypochondria) and for care providers to over-test and over-medicate (avoid malpractice and promote snake oil). Either you use market-based incentives or bureaucratic incentives. And the bureaucratic incentive can be public or outsourced to commercial enterprise. There is no spontaneously self regulating system, it has to be designed-in.

Yves Smith Post author , February 22, 2019 at 6:26 am

Bullshit. Every other advanced economy had a fully or heavily government funded system. Their costs are 50-60% in GDP terms compared to ours with generally better health outcomes.

Hypochondria is present in only 1-5% of the population. That isn't a "tendency". The overtesting is due mainly to bad norms and bad economic incentives like it being perceived to be normal to have an EKG every year with your annual physical (another questionable practice in healthy people) when only people at heart disease risk need an EKG. MDs own the EKG equipment, so this is a profit center for them. Similarly, I knew instinctively that annual mammograms and annual Pap smears were overkill and I'd refuse those tests and get lectured for that. My take has now been confirmed. But those MDs were driven by bad collective beliefs as to what good medical practice was at the time, and not some personal liability fear.

As for overprescribing, again my perception is that this is more patient that MD driven (save possibly for elderly people who tend where they should be taken off certain meds for a month or two and tested to see if they are still needed). You forget that Big Pharma now advertises on TV and tells patient to ask their doctors about their wares! But the real sins like prescribing antibiotics for flus comes (as in with other cases) with patients wanting the doctor to Do Something.

I lived in Australia and MDs were very much of the "let's monitor this" (as in do nothing right now) school, which says that patients are perfectly fine with that if the doctor seems confident and also make clear that he'll change course if warranted.

MDs ought to be allowed to prescribe placebos or aspirin at real med prices with some mystery med name and have the pharmacy plan quietly rebate virtually all the price months later for the patients with real problems where meds are indicated (the problem need to run its course and the most that is called for is palliatives).

Redlife2017 , February 22, 2019 at 6:54 am

+1000
From my own experience I completely agree. In particular with your point about the Doctors being in the "let's monitor this" school of thought outside of the US.

I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement).

In the UK a doctor will never overprescribe – even if you want them to. It's just not a thing at all since there is no incentive except to be a, uh, doctor. They are trying to make sure you either get or stay healthy.

The system is built to make sure people have healthcare without weird profit incentives. They even have signs at the GP stating that if you have flu you should just rest, drink lots of fluids and stay home – don't get other people sick.

And to pre-empt someone noting that the NHS is having lots of problems – that is completely the choice of the current government (and the government in their ConDem days of 2010 – 2015). The NHS would be in much better shape if they

  1. stopped all the stealth privatisation (it's shocking what is going on) and
  2. just made sure local services were properly funded.

Amfortas the hippie , February 22, 2019 at 7:55 am

aye. the stealthy neoliberal colonisation of NIH, and all the scandinavian happy places is studiously ignored.

with my own experience with healthcare -- 6 1/2 years to get a hip to replace the literally dead one i was hobbling around on and now, all the time i've spent in and around the gleaming medical center for my wife's cancer .talking to all and sundry listing to all and sundry from wastrels at the bus stop to suits riding the elevator with me healthcare is a Right, dammit. there is no place at all for markets, privatisation or profit. it is immoral to profit off the suffering of a human being, period.

that moral argument is what will win the day even the suits acknowledge it, before passing off responsibility to the System("well, yes but we can't do anything, because the Great God Moloch must be appeased")

I am a sacrificial victim to that cruel deity. I'll be in pain for the rest of my life because i couldn't get timely care i still walk around on an ankle that is an enervated bag of gravel, since no ankle guys in texas take medicaid (and i'm kicked off that, now, too,lol)

I am thankful for my hip, hard won as it was. and i am more than grateful for the level of care my wife is getting but damn.

let these ceo's walk a mile or two in bloody shoes before they lecture about affordability and access.

their sin is gross indifference to suffering in the service of their own greed.
fie.

Susan the Other , February 22, 2019 at 12:18 pm

Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay.

This is nothing more than an obfuscation of blatant extortion. Do any of these patriotic capitalists understand capitalism? I don't think so. Too much liike a priest understanding god. Is god otherwise unaffordable, if you don't have a pious priestly middleman to do spiritual arbitrage? For a small fee, of course.

They really do think we are stupid. But they forget The Reformation. There just comes a point in time when you can't politely ignore the lies and destruction. It takes on a life of its own and is unstoppable.

This post is encouraging because there is a guy out there named Roy Poses who is connected with something called Health Care Renewal and there is another guy, Paul Waldman who works for the WaPo; and we are reminded of the wonderful Mr. Wendell Potter. And a whole nation on the march. Hope your hip and your wife are feeling better.

GF , February 22, 2019 at 12:29 pm

Here's a retweet from Bernie about the latest big pharma price gouge:

"Bernie Sanders
‏Verified account @SenSanders
Feb 20

Bernie Sanders Retweeted CNN Health

Catalyst's decision to raise the price of a life-saving drug from $0 to $375,000 is causing patients to suffer and ration their medication. Outrageous! Catalyst must immediately lower the price of Firdapse."

PlutoniumKun , February 22, 2019 at 10:37 am

A relative of mine is actually nearly through research on exactly the topic of prescribing differences between Europe and the US. He says he found a very different culture among US doctors (if and when its published I'll certainly let Yves know, it might make an interesting article or link here).

As you and Yves says, there is very little evidence of overprescribing or overtreatment in 'free' or heavily subsidised health systems. On the contrary, there is evidence of massive overtreatment in the US for people willing to pay and / or with good insurance.

Here in Ireland there were problems in hospitals because it used to be free to be an out-patient, so the poor/hypochondriac, etc., would clog up waiting rooms instead of going to their local doctor where they would have to pay. They introduced a charge solely to stop this. It was crude, but it worked. It would of course have been much better to co-ordinate charges or put a better system in place to triage real patients from those who just want a bit of sympathy.

Most GP's will tell you that about 5% of their patients represent 90% of their workload. Some people either need lots of care, or they are just demanding and go to the doctor for every little ache and pain, while others practically have to have a limb falling off before they'd go. That's just the way it is, and all systems come up with ways to deal with it.

Nearly all doctors will give prescriptions even when not needed, because they know people feel better for it. The doctors I know invariably give mild painkillers on prescription for minor things like colds and backaches. Its really a form of acceptable placebo. I'm lucky to have a really good local doctor who runs a small team who are very firm on explaining to people why they don't always need treatment or prescriptions, even to the point of it being a little annoying sometimes – he refused to burn off a wart I had some time ago, telling me just to go to a pharmacy and buy an over the counter freeze tab. And when I had a diagnosis for mild arthritis in my hip he told me to walk lots and eat natural anti-inflammatory foods – again, no prescription, even something very mild. He seemed surprised that I didn't argue the point.

That said, being strict on prescriptions can backfire. I know of a young man who died from a rare bone cancer. He was from a very poor background and looked like a typical junkie – pale skin, skinny, Nike sweat pants (he wasn't, he just looked like one). His doctor thought he was trying to scam opiates and told him the pain was all in his head.

He was a little bit innocent and believed her.

It was when he literally collapsed while visiting his girlfriend in hospital that he was examined and diagnosed – it was too late by then.

Carla , February 22, 2019 at 12:05 pm

Yves, thank you so much for calling bullshit on Disturbed Voter's comment. After spending more than two decades as a single-payer supporter, I cannot improve upon your response.

Disturbed Voter , February 22, 2019 at 12:33 pm

i work in medicine, do you? Mind you, you can have single-payer or Medicare-for-all but it isn't free (not free in Cuba or other locations).

And medical care will always be triaged on some basis so expect delay or denial of care.

What you see is dishonest accounting, moving costs from one column to another, and hiding the change.

And providers won't work for free either, unless you intend to enslave them. I am happy France etc has good open access care. You might ask how that is done, it isn't magic. The answer is, they pay high taxes, and don't spend that on things they don't want (like endless warfare). As far as drug prices go, Americans subsidize the cheaper prices found elsewhere (not that I agree do this).

AdamK , February 22, 2019 at 12:35 pm

+100000. It is also very common to create a package of services that are provided by the government insurance and leave the rest to private insurance. This package is revised every few years according to scientific reviews and adds or drops services. Plastic surgeries are out unless there's significant affects to the person'e quality of life. If a patient is interested in an experimental, or not proven, innovation, he can shop for it himself as long as there's solution that is covered. The same way private insurance deals with such cases presently. As for meds, with big data you can pinpoint to a patient that over uses or a physician who over prescribes, and use this info for integrative medicine purposes to optimize the use of meds to better results. Those methods do not go well with the healthcare industry of course. No one now has an incentive to cut services or meds.

In general every method has it wastes and frauds which cannot be quantified in advance, the issue here isn't just cost, it is first and foremost MORAL.

Mark , February 22, 2019 at 6:04 am

As a non American, I find it quite bizarre when claims like this are made. Universal health care and free/affordable quality education is available in many countries that are far less prosperous than the United States.

If only the US could look outside it's bubble and take a few hints from how things are done elsewhere. However being the "leader" of the "free world" seems to make the USA blind to looking outside its own sphere for how things could be done better.

(Not that the US is alone here. But it probably is one of the stronger examples.)

notabanker , February 22, 2019 at 7:30 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

Americans do live in bubbles, and within the US there are bubbles, the country is so vast and it's media is captured. I find it encouraging when people like yourself speak up and call bullshit. I've seen some of Sanders healthcare threads on twitter completely ratio'd with Canadian, British and Aussie's calling BS on the US propagandists that try to attack their systems. We need more of that.

Kurtismayfield , February 22, 2019 at 9:49 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

You have to consider their news sources as well.. my theory is that the only point of the 5 and 6 O'clock news is to feed into middle class anxiety or advertise a product. The corporate run media wants people scared and to buy buy buy. I would love to see a politician start a campaign where they discuss 20 different country's health care systems that are better and cheaper than ours, and see how deafening the silence will be from the corporate media.

As I have said here many times before, just get someone to propose the Swiss system . Anyone that argues that the Swiss are some bastions of communist thought can be laughed at entirely.

notabanker , February 22, 2019 at 11:36 am

I did mention the media being captured. And unlike the UK, there is no European influence to counter / add breadth to the BBC. Brits and Europeans have a far more global-centric view of things, if for no other reason than geography.

Phacops , February 22, 2019 at 10:01 am

Having to work in other countries provides a swift reality check regarding ways of social organization and doing things. I count such experiences as saving me from believing conservative propaganda here in the US.

notabanker , February 22, 2019 at 11:54 am

I am so very glad my kids spent crucial formative years outside of the US. It's the best possible gift I could have ever given to them.

Phacops , February 22, 2019 at 9:53 am

What do you expect for a people who actually hate to travel except for pre-programmed experiences or resorts walled off from the surrounding community? That, and the lack of adequate holiday time to even enjoy their own country. I don't wonder at the ignorance of the American public about better ways of providing human services and better health outcomes, though I think some such ignorance is deliberate.

Buzz , February 22, 2019 at 12:02 pm

How very, very true Mark. I've yelled and screamed this same meme over and over to no avail. Look around, we're not the only country on this planet and we DON'T always have the right answers !

Grant , February 22, 2019 at 12:40 pm

On so many issues though in this country, when we talk about the "US", we should be clear about what we are talking about. The opinions of rich people in the media, rich and corrupt politicians, strongly ideological people with a class bias that are appointed by politicians, and paid propagandists and "think tanks" don't constitute the country. I don't think that those groups have anything to learn about other countries because I think most of them are fully aware that they are not being logically factual or honest in what they say on healthcare, the critiques they give of single payer, etc. Some people maybe are (willfully) ignorant, but I think most of it is gaslighting. It doesn't matter that every single payer system has lower overhead, is more efficient, has far less social costs, is cheaper as a percentage of GDP and on a per capita basis. It doesn't matter the reasons why this is the case. There was a WHO study in 2010 that showed that administrative overhead in private systems around the world is three times higher than overhead in public systems, and why that is the case. It doesn't matter how many studies show massive aggregate savings from adopting single payer here. The data on overhead with traditional Medicare versus private insurance, polls showing that the public parts of the healthcare system (the VA, Medicare, Medicaid) are all more popular than private insurance or things like the Rand study showing that care at VA hospitals are often better than the care veterans get at private healthcare providers. None of it matters, if any person on TV actually cared about factual accuracy on stuff like this, they wouldn't be on TV. Someone else that was willing to manipulate people and lie would be in their place, and they would be paid well to do so instead of them. You can't tell me that Jake Tapper isn't fully aware of what he is doing when he "fact checks" single payer like he has done.

The public, however, does seem to get it, especially when things are described accurately to the public. Kaiser does polls, they are opposed to single payer, and so they frame their questions in really biased ways. For example, they will ask, would you support single payer if it raised taxes? Well, some respondents say not, although there is still majority support. Beyond the MMT arguments of not needing to raise taxes, let's just assume that we are trying to make single payer as revenue neutral as possible, for arguments sake. Wouldn't a more accurate question be, would you support single payer if it raised taxes, but the tax increases were more than offset by a reduction in out of pocket expenditures? Polls show strong majorities of the country support single payer, and that is with very little of those in power and with big microphones supporting the idea. We all know the studies showing the large gap between popular opinion and what the state does on policy. Like every other issue, people want one thing, and worthless people in power want another, and our system doesn't make it so that those worthless people are really directly controlled by us collectively nearly as much as donors and other interests control them.

greg , February 22, 2019 at 6:34 am

Since it is becoming increasingly obvious that our current management team of wealthy white males are both too venal and too incompetent to sustainably manage a global economy, perhaps we should start looking for alternatives.

It is delusional to think that US healthcare, or any of the problems which beset both the United States and the world, will be effectively dealt with as long as they are in charge.

It is unreasonable to expect that the over exploitation of natural resources, or sustaining the environment, addressing global warming, and so forth, will happen under their management. This is simply because they are the ones who control the earth's resources, and they are the ones who most profit from their unregulated exploitation and destruction.

It is unreasonable to expect that pollution will be effectively dealt with, because the wealthy make a profit from every ounce of pollution, and every scrap of litter, that has ever been, or will ever be, produced.

Every ounce of CO2 produced, is profit for some wealthy businessman.

Overpopulation is profitable for the wealthy. It both expands their market for goods and services, and lowers their price for labor.

Have you not noticed that we have been aware of all of these problems for over 50 years, and nothing has actually been accomplished with any of them?

Nothing effective will be done, with any of these problems, while they are in charge. It's all been talk, talk, talk, and from the wealthy, always the seeds of confusion and division.

Once a problem has been solved, it is no longer an opportunity for profit. As long as a problem festers, there is money to be made.

Every cost imposed on society is a profit opportunity for someone with wealth and power. There is money to be made, as civilization declines and collapses.

Mac na Michomhairle , February 22, 2019 at 9:23 am

You seem to start of suggesting that things would be fine, if it were not for wealthy white males being in charge.

That is a peculiar perspective that appears to attempt to divert attention from the actual horrifying system itself, and divert potential energy from attempts to change that system, to focus on a mere feature of the system.

As though, if an investment house screwed over my parents, I devote myself to bettering the world by fighting the men of Connecticut wherever I encounter them, because the house agent who was point person was from Connecticut.

If individuals in the system stand to profit from it, of course they have a stake in its continued existence; any individuals do.

Mike Mayer , February 22, 2019 at 7:39 am

Why don't businesses in the USA want to have the burden of providing health insurance taken away from them? It is a cost they bear because they need to find, negotiate, buy and administer the health plan. I am surprised most businesses are not lobbying to have the government provide it.

voteforno6 , February 22, 2019 at 9:44 am

On the other hand, the system of employer-based health insurance does offer additional ways for employers to keep the serfs in line.

rd , February 22, 2019 at 10:50 am

I tend to align with incompetence and neglect in lieu of conspiracy theories if the former can explain it, because it takes a lot of effort and smarts to pull off a conspiracy and both of those are usually in short supply across a large population.

I think we have most companies for whom the health insurance system is just something they have to have and they just go along with the flow because their competitors based in the US have similar costs.

The one organized group on this is the healthcare industrial complex that are lobbying against any nationalization type of change and even want to get more into the VA and Medicare than they already are. This IS their business and they are focused on it like a laser beam. so the conspiracy theory works for their sector.

BTW – I am surprised that the inexpensive healthcare in the rest of the developed world hasn't been a talking point of Trump's as a "subsidy" to their businesses justifying retaliatory tariffs by the US. The difference between what the US and the rest of the developed countries spends on healthcare is bigger than the entire US military budget as a percent of GDP, never mind the delta between US military spending and the other G-20 countries. So if we could drop our health care per capita spending to a bit below Switzerland's (next highest), we would have paid for the entire US military budget. If we could drop it down to Canada's level, we would have saved a year and a half's US military budget every year.

And "American Exceptionalism" pretty much ensures that nobody will look outside the US borders for solutions. If we are doing it, then it must be the best way. End of story. No further research required.

jrs , February 22, 2019 at 1:03 pm

besides the fact that it only makes a little bit of sense even as a conspiracy theory, a few people work just for healthcare and would retire otherwise (they are of course comparatively well off it goes without saying, and yes they SHOULD be able to retire, make room for those who actually NEED to work!).

But most work for survival day to day and if healthcare comes with it that's great, but many work without any form of employer provided healthcare at all (because they still need money to survive). I've heard 30-40% of the working population has NO employer provided healthcare. The serfs are still kept in line just by even more basic needs like food, shelter, and climate control, or they wouldn't show up for such jobs, but of course they do.

tegnost , February 22, 2019 at 9:59 am

IMO it's because they like the captive employees who won't quit because health care

Jim Thomson , February 22, 2019 at 12:51 pm

Bingo.

antidlc , February 22, 2019 at 10:18 am

As mentioned by other posters, companies want to use healthcare to keep employees captive. They don't want employees to leave for smaller firms or start their own companies. It's a way to limit competition.

Companies also have a vested interest in keeping the employer-based insurance model:
https://www.wsj.com/video/why-big-tech-wants-access-to-your-medical-records/F9C51DC8-5238-4D0C-B8BD-73F0FAC92048.html

They want to be able to use your medical history to decide whether to hire or fire you. The video is quite alarming.

oaf , February 22, 2019 at 8:00 am

" the financial health of the insurance industry"

Perhaps Government should mandate the profitability of all sectors of the Economy
..or justify why they pick *favorites*

Got to keep the trough full; that's an important pig!

oaf , February 22, 2019 at 8:17 am

lest we throw out the Baby with the bathwater; let's bathe in it a while longer!

zagonostra , February 22, 2019 at 8:19 am

> It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

Unfortunately, I think in the aggregate both are true: They are not stupid, rather cunning and evil, we are stupid, or rather easily manipulated by a very sophisticated propaganda machine that goes back to Edward Bernays. If you repeat a lie often enough it doesn't matter if it's true or not, and by the processes of association (socialism/Venezuela) we are wired in ways that makes us susceptible to blaring lies (some of Koestler's works come to mind).

There has to be a tipping point where enough people have built up defenses to the propaganda that enable "we" to go after the bloody bastards.

tegnost , February 22, 2019 at 10:16 am

I think it's less a matter of defenses and more the numbers game, the PTB have been pretty successful winnowing the field. Say a 1000 people work in an industry, someone of those 1000 figures that 100 of those can be replaced (h1b, computers, undocumented immigrants) but the amount they charge stays the same, or more likely is increased to reflect the leaner machine being more productive. Big bonus to top guy. Then it's well we have 900 employees, we could do the same with 700 employees etc and on down the line. This has worked really great for the 40 years since reagan. Add crippling student loan debt, winnow out some more people as they have been effectively neutered, basically only able at best to maintain as a steadily depreciating labor unit (hmmm, we need that persons shoes to touch the ground in a medical establishment so the gov can pay us, since that poor schlub obviously can't, thanks ACA, and once again imo, the whole reason for the medicaid aspect of the ACA) the end result is fewer and fewer successful lives being led, and more and more precarious lives being led. In 2016 the dogs wouldn't eat the dogfood. Nothing about the numbers have changed so the dogs are going to be more grumpy and indeed some of those dogs which sat on the sidelines last time might be grumpy enough to vote in 2020.

katiebird , February 22, 2019 at 8:39 am

It seems like there is a logical fallacy somewhere in this story. .

Arizona college student could die because she can't get copies of her medical records

The files are locked away in a repossessed electronic-records system while creditors of bankrupt Florence Hospital at Anthem and Gilbert Hospital bicker over who should pay for access to them.

.

The medical records are the only thing standing between her and a lifesaving surgery by a top physician at Johns Hopkins Hospital.

The doctor has refused to perform the operation without a complete understanding of Secrist's health history, including what her pancreas looked like when she was originally diagnosed, she said.

Every week that goes by, the danger increases of another attack of acute pancreatitis that could cause her organs to shut down.

"Without those records, we can't go forward. We can't make me better," said Secrist, who lives with her parents in Florence. "Having my life, practically, in the hands of a judge and people I don't even know, who don't even know my situation, it's upsetting."

Secrist and her primary-care physician sent letters this week to Maricopa County Superior Court urging swift release of her records. Federal and state law require medical facilities to send patients copies of their medical records within 60 days of a request.

taunger , February 22, 2019 at 9:00 am

Thank you for this post that clearly identifies the logical fallacies. This can be useful in conversations #fieldwork

Norb , February 22, 2019 at 9:04 am

In the long run, Medicare-for-all lays the groundwork for a more healthy and productive society. Healthy citizens require less healthcare, so there is potential savings over time. Healthcare is most efficient when built around a healthy society. But healthy citizens must be the primary goal, not some abstract argument about affordability and jobs protection. The jobs created by the system must be oriented toward societal health, not the profit generation for a few plutocrats. No wonder they are bemoaning the cost- they have been impoverishing the citizenry for 40 years and sooner or later that bill has to be paid.

The plutocrats, always attempting to hide their true motives, now seek to obfuscate their abject disdain for working people by using arguments of cost to continue restricting access to healthcare. Their inhumanity must be driven home and called out, but the social discourse is still in "polite" mode. Using the term 'stupid' to describe the plutocrats falls in this category. They know exactly what they are doing, and are given a social pass to continue acting in an inhumane and antisocial manner. Chants of USA USA are obscene in this context. The longer this trend continues, only decline can result.

If people are not responsive to a moral argument, the argument for comparative costs is the strongest one that needs to be constantly driven home. We are already paying- and as pointed out, will be paying much more in the future for less. Everyone can understand that and can see it in their own pocketbooks.

The moral bankruptcy of the current leadership must be called out. The propaganda bubble that Americans live enshrouded in is showing signs of weakness. That bubble will burst when pricked from forces outside the impirum- and there are many- failure is everywhere and the rest of the world is not as delusional as most Americans.

a different chris , February 22, 2019 at 9:19 am

Do these billionaires realize that, in this case the word "unaffordable" specifically means "go die"? Wow.

bassmule , February 22, 2019 at 9:27 am

As Lambert has frequently pointed out, NeoCon policy regarding health is this:

1. "Because markets!'
2. "Go die!"

voteforno6 , February 22, 2019 at 9:46 am

That's NeoLib The NeoCons are the ones who want to bomb everything, everywhere, because America.

polecat , February 22, 2019 at 11:19 am

Put the two together, and you have two wretched greedy fingers locked in avaricious embrace !

JBird4049 , February 22, 2019 at 12:15 pm

The two sets have been merging to where they would be almost the same in a Venn diagram. Almost the entire Washington establishment agrees on what is call the Washington Consensus which is cutting taxes, reducing regulations, free trade, and now apparently the Forever Wars.

Most of the differences that remains are cosmetic and focus on the social issues so that the selected base will organize, donate, and vote for them.

For example, gun control, LGBT rights, and pro-choice (abortion) for the Democratic Party and gun rights, religion, and pro-life (anti-abortion). Note that the goal is not to solve or even ameliorate any issue, but rather to inflame them so that they can be used as cover, distraction, and agitation.

Carolinian , February 22, 2019 at 9:46 am

It's all about the Benjamins–logic has nothing to do with it and never has. The largest business in my county is the hospital system which also has the highest paid CEO. And they just became even larger by buying a smaller competing hospital. Yves has pointed out how fearsome the DC health lobby is and, as cited above, the Chamber of Commerce is fully on board. There's been some excitement because announced Dem pres candidates support Medicare for all but Dem candidates always say they are for reform whereas in reality we get Hillary care in the '90s or Obamacare after both he and Hillary campaigned on the issue. Probably none of this will stop unless the economy crashes to the point that the medical complex has to accept reform and reality.

justsayknow , February 22, 2019 at 10:14 am

''That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That's not correct. That's not American,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

I'd say Shultz gives the game away as he reveals he sees the current "system" as a make-work-make profit center.
I imagine he and Bloomberg et al have significant investments in the health industrial complex. Otherwise wouldn't it benefit all other commerce sectors to have customers with lower health costs thereby freeing up money that could be spent with them.

Eclair , February 22, 2019 at 12:22 pm

"What industry are we going to abolish next?"

Great question, Schultzie! Where were you (or your ilk) when we 'abolished' the US textile industry? Or our furniture industry? Or our electronics industry? Or our clothing industry? Or our rail car manufacturing industry?

And the jobs that went with them.

antidlc , February 22, 2019 at 10:23 am

More from Wendell Potter:

How to be ready for the health care industry lie factory
https://www.tarbell.org/2019/02/be-ready-for-the-health-care-industry-lie-factory/

antidlc , February 22, 2019 at 10:26 am

Meet the propaganda outfit fighting against Medicare for All (podcast)

Why do we believe the things we do? Whistleblower, New York Times best selling author and Tarbell.org founder Wendell Potter, along with millennial co-host Joey Rettino, are joined by politicians, activists, journalists and pretty much everybody else to figure it out.

https://www.tarbell.org/2019/02/the-potter-report/

Summer , February 22, 2019 at 10:26 am

I laugh when they say they are worried about "jobs" of people in the health insurance industry. They aren't worried about the jobs, but exec pay. Everytime I look up there are articles about more automation and tech in the administrative and medical pafts of the industry.
It's like Uber claiming to worry about drivers while claiming their future is driverless cars.
So a good number of people that staff the health insurance industry (talking to you non-wealthy execs) need to get on board now and get their health care covered.

There aren't too many industries that aren't salivating overways to have fewer employees and then you hear all this BS from the same industry "leaders" touting how employer based system is the only thing imaginable.

rd , February 22, 2019 at 11:12 am

BTW – latest number I can find

Canada military spending 1.0% of GDP; healthcare spending 10.4%: Total military + healthcare = 11.4% of GDP

US military spending 3.5% of GDP; healthcare spending 16.9%: Total military + healthcare = 20.4% of GDP

So between those two economic sectors, Canada has an extra 9% of GDP to spend on other priorities. No wonder they can have an inflated housing market as well as paid parental leave.

Disturbed Voter , February 22, 2019 at 12:41 pm

Exactly. To reallocate resources, you have to look at the whole picture, not just the health industry. That is a huge question. What you do with a particular allocation, is pertinent.

D , February 22, 2019 at 11:13 am

i always wonder if they are really thinking through when the say that the government (us) but that if we let patients and insurance can pay for it?? Really????

Susan the Other , February 22, 2019 at 12:45 pm

Thanks for this post, Yves. It was really good. It did all the demolishing for us. Deconstructing the whole building. I love the phrase (whether facetious or not) "argument by gibberish." I mean, it could be a necessary part of a logic curriculum – please analyze this argument for gibberish – because we were once so oblivious. So, more accurately, the pushers are now the oblivious ones. The full court press against "socialism" and "unaffordable health care" and holding up the decrepit free market isn't going to work much longer.

Hepativore , February 22, 2019 at 12:58 pm

One thing that I also hope that gets changed in the US, is combining dental care with a Medicare For all Program. It is ridiculous that people have to carry both dental and health insurance as good dental care and physical well-being are related. Left untreated, oral maladies can quickly become serious and more expensive to treat. Effective dental care is far from a vanity service.

[Feb 22, 2019] Angry Bear Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Feb 22, 2019 | angrybearblog.com

Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

run75441 | February 21, 2019 10:00 pm

Healthcare Hot Topics This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, "annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013." This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly's Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? "The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero." Just like slapping "new and improved" on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article ("Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years ") explains, "most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums." This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty "Tom" and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

"the message from Department of Health and Human Services stresses the vast savings possible through a less 'fragmented and integrated' health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs"; "while on the other side of the Mall, 'pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors' practices merging and using their resulting monopoly power to drive up prices."

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI) . It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.

Resources

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Zack Cooper Hospital Care Prices Rose Faster Than the Cost of Physician Services, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014


Mike Kimel , February 22, 2019 5:46 am

I have the impression that it has gotten harder to see a doctor or get a prescription filled over time. A couple of decades ago either your insurance paid or it didn't. Now it seems to me that most people have stories about arguing with insurance companies. It is sort of expected to be a part of the process. Time costs like this aren't counted with a dollar value but they surely contribute to the negative experience, and they require additional admin people at both medical providers and insurance companies. That in turns leads to more documentation and paperwork, requiring even more admin people. It's one thing if the extra personnel are a force multiplier allowing more people to be serviced. It's another if they are an impediment and an added cost.

Denis Drew , February 22, 2019 11:28 am

The political forum is too "understaffed" on all topics to fight back against (a nation of) scams because of (you know what I'm going to say) the disappearance of labor unions. Late Dean of the Washington press corps, David Broder, told a rookie reporter that when he came to DC the lobbyists were all union.

Nice to get real -- math broken down -- info beginning to tell why we pay twice as much for health care as any other country. When you add the hospitals overcharging, the drug companies bleeding us literally to death and the private insurance paper work overload, maybe we are finally sorting it out, at least a bit.

likbez , February 22, 2019 3:35 pm

The relationship between hospitals and heaths insurance companies currently somewhat resembles criminal cartel.

Often hospitals perform on the patient procedures that are best paid by the insurance companies, even if they are unnecessary, or even harmful.

An epidemic of unnecessary cardiac stents insertions in the USA is a nice illustration of the trend for costly and unnecessary (or even dangerous for the patient) procedures . Hospital cardiologists are pushed by financial incentives

"chief cardiologist Steven Nissen at the renowned Cleveland Clinic noted that doctors are paid per procedure rather than on a salary basis, while the Mayo Clinic's chief of cardiology, Raymond J. Gibbons, also cited the financial incentive of performing procedures."

And only few cardiologists that practice this racket went to jail.

That somewhat resembles relations between the car insurers and the body shops ;-)

[Jan 21, 2019] The Social Contract According to Elizabeth Warren

Notable quotes:
"... Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares. ..."
"... Warren Supports Medicare for All Only Nominally ..."
"... Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it? ..."
"... Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope ..."
"... but only through the institutional framework of unions ..."
"... Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ..."
"... I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference. ..."
"... Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin. ..."
"... The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech). ..."
"... The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist. ..."
"... Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won. ..."
"... " Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives . ..."
Jan 21, 2019 | www.nakedcapitalism.com

Posted on January 20, 2019 by Lambert Strether New America (board chair emeritus Eric Schmidt , President the aptronymic Anne-Marie Slaughter ), a nominally center-left Beltway think tank ( funding ) " took up the mission of designing a new social contract in 2007 and was the first organization [anywhere?] to frame its vision in these terms." On May 19, 2016, New America sponsored an annual conference (there was no 2017 iteration) entitled "The Next Social Contract." Elizabeth Warren, presidential contender, was invited to give the opening keynote ( transcript , whicn includes video). Warren shared a number of interesting ideas. I will quote portions of her speech, followed by brief commentary, much of it already familiar to NC readers, in an effort to situate her more firmly in the political landscape. But first, let me quote Warren's opening paragraph:

It is so good to be here with all of you. And yes I will be calling on people. Mostly those of you standing in the back. I always know why people are standing in the back. That's what teachers do.

Professional-class dominance games aside, it's evident that Warren is comfortable here. These are her people. And I would urge that, no matter what policy position she might take on the trail, these policies and this program are her "center of gravity," as it were. Push her left (or, to be fair, right) and, like a bobo doll , she will return to this upright position . So, to the text (all quotes from Warren from the transcript ). I'll start with two blunders, and then move on to more subtle material.

Warren Does Not Understand Uber's Business Model

Or, in strong form, Warren fell for Uber's propaganda.[1] Warren says:

Thank you to the New America Foundation for inviting me here today to talk about the gig economy You know, across the country, new companies are using the Internet to transform the way that Americans work, shop, socialize, vacation, look for love, talk to the doctor, get around, and track down ten foot feather boas, which is actually my latest search on Amazon .

These innovations have helped improve our lives in countless ways, reducing inefficiencies and leveraging network effects to help grow our economy. And this is real growth . The most famous example of this is probably the ride-sharing platforms in our cities. The taxi cab industry was riddled with monopolies, rents, inefficiencies. Cities limited the number of taxi licenses

Uber and Lyft, two ride-sharing platforms came onto the scene about five years ago, radically altered this model, enabling anyone with a smartphone and a car to deliver rides . The result was more rides, cheaper rides, and shorter wait times.

The ride-sharing story illustrates the promise of these new businesses. And the dangers. Uber and Lyft fought against local taxi cab rules that kept prices high and limited access to services .

And while their businesses provide workers with greater flexibility, companies like Lyft and Uber have often resisted efforts of those very same workers to try to access a greater share of the wealth that is generated from the work that they do. Their business model is, in part , dependent on extremely low wages for their drivers.

"In part" is doing rather a lot of work, there, even more than "the wealth that is generated," because NC readers know, Uber's business model is critically dependent on massive subsidies from investors, without which is would not exist as a firm. Hubert Horan (November 30, 2016):

Published financial data shows that Uber is losing more money than any startup in history and that its ability to capture customers and drivers from incumbent operators is entirely due to $2 billion in annual investor subsidies. The vast majority of media coverage presumes Uber is following the path of prominent digitally-based startups whose large initial losses transformed into strong profits within a few years.

This presumption is contradicted by Uber's actual financial results, which show no meaningful margin improvement through 2015 while the limited margin improvements achieved in 2016 can be entirely explained by Uber-imposed cutbacks to driver compensation. It is also contradicted by the fact that Uber lacks the major scale and network economies that allowed digitally-based startups to achieve rapid margin improvement.

As a private company, Uber is not required to publish financial statements, and financial statements disseminated privately are not required to be audited in accordance with generally accepted accounting principles (GAAP) or satisfy the SEC's reporting standards for public companies.

The financial tables below are based on private financial statements that Uber shared with investors that were published in the financial press on three separate occasions. The first set included data for 2012, 2013 and the first half of 2014 The second set included tables of GAAP profit data for full year 2014 and the first half of 2015 ; the third set included summary EBITAR contribution data for the first half of 2016. .

[F]or the year ending September 2015, Uber had GAAP losses of $2 billion on revenue of $1.4 billion, a negative 143% profit margin. Thus Uber's current operations depend on $2 billion in subsidies, funded out of the $13 billion in cash its investors have provided.

Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares.

Many other tech startups lost money as they pursued growth and market share, but losses of this magnitude are unprecedented; in its worst-ever four quarters, in 2000, Amazon had a negative 50% margin, losing $1.4 billion on $2.8 billion in revenue, and the company responded by firing more than 15 percent of its workforce. 2015 was Uber's fifth year of operations; at that point in its history Facebook was achieving 25% profit margins.

Now, in Warren's defense, it is true that she, on May 19, 2016, could not have had the benefit of Horan's post at Naked Capitalism, which was published only on November 30, 2016. However, I quoted Horan's post at length to show the dates: The data was out there; it wasn't a secret; it only needed a staffer with a some critical thinking skills and a mandate to do the research to come to the same conclusions Horan did, and Uber's lack of profitabilty, easily accessible, is a ginormous red flag for anybody who takes the idea that Uber "generates wealth" seriously. How is it that the wonkish Warren is recommending policy based on what can only be superfical research in the trade and technical press? Should not the professor have done the reading?[2]

Warren Does Not Understand How Federal Taxation Works

The second blunder. Warren says:

First, make sure that every worker pays into Social Security, as the law has always intended. Right now, it is a challenge for someone who doesn't have an employer that automatically deducts payroll taxes to pay into Social Security. This can affect both a worker's ability to qualify for disability insurance after a major [injury], and it can result in much lower retirement benefits. If Social Security is to be fully funded for generations to come, and if all workers are to have adequate benefits, then electronic, automatic, mandatory withholding of payroll taxes must apply to everyone , gig workers, 1099 workers, and hourly employees.

It is laudable that Warren wants to bring all workers in the retirement system. But as NC readers know, Federal taxes do not "pay for" Federal spending, and hence Warren's thinking that Social Security will be "fully funded" through "payroll taxes" is a nonsense (and also reinforces incredibly destructive neoliberal austerity policies). I will not tediously rehearse MMT's approach to taxation, but will simply quote a recent tweet from Warren Mosler:

me title=

And if Mosler isn't good enough, here's John Stuart Mill on currency issuers:

me title=

Again, is it too much to ask that a professor do the reading? After all, MMT gotten plenty of traction, even in 2016. The Sanders staff, for example, could have been helpful to her .

Warren Supports Medicare for All Only Nominally

Warren is indeed a co-sponsor of Sanders' ( inadequate ) S1804. But read the following passages, and you will see #MedicareForAll not where her passion lies:

As greater wealth is generated by new technology, how can we ensure that the workers who support the economy can actually share in the wealth?

(The idea that workers "support" "the" [whose?] "economy," instead of driving or being the economy, is interesting, but let that pass.)

Warren then proceeds to lay out a number of policies to answer that question. She says:

Well, I believe we start with one simple principle. All workers, no matter where they work, no matter how they work, no matter when they work, no matter who they work for, whether they pick tomatoes or build rocket ships, all workers should have some basic protections and be able to build some economic security for themselves and their families. No worker should fall through the cracks. And here are some ideas about how to rethink and strengthen the worker's bargain.

So, she's not just laying out policy for the gig economy (the occasion of the speech); she's laying out a social contract (the topic of the speech). Picking through the next sections, here is the material on health care:

We can start by strengthening our safety net so that it catches anyone who has fallen on hard times, whether they have a formal employer or not. And there are three much-needed changes right off the bat on this.

I hate the very concept of a "safety net." Why should life be like a tightrope walk? Who wants that, except crazypants neoliberal professors, mostly tenured? She then makes recommendations for three policies, and sums up:

These three, Social Security, catastrophic insurance, and earned leave, create a safety net for income.

Hello? Medical bankruptcy ?[3] She then moves on from the "safety net" for income to benefits, which is the aegis under which she places health care:

Now, the second area of change to make is on employee benefits, both for healthcare and retirement. To make them fully portable. They belong to the worker, no matter what company or platform generates the income, they should follow that worker wherever that worker goes. And the corollary to this is that workers without formal employers should have access to the same kinds of benefits that some employees already have.

I want to be clear here. The Affordable Care Act is a big step toward addressing this problem for healthcare. Providing access for workers who don't have employer-sponsored coverage and providing a long term structure for portability. We should improve on that structure, enhancing its portability, and reducing the managerial involvement of employers.

Remember, this is a Democratic audience, and what do we get? "Portability," "access", and reduced "managerial involvement." That's about as weak as tea can possibly get, and this is a liberal Democrat audience. ("The same kinds of benefits that some employees already have." Eeesh.) But wait, you say! This speech iis in 2016, and in 2018, Warren supports #MedicareForAll! For example, " Health care: Supports the "Medicare for All" bill led by Bernie Sanders " (PBS, January 17, 2019). But notice how equivocal that support is. Quoting PBS again, Warren "called that approach 'a goal worth fighting for.'" Rather equivocal! And folliowing the link to that quote, we find it's from a speech Warren gave to Families USA's Health Action 2018 Conference :

I endorsed Bernie Sanders' Medicare for All bill because it lays out a way to give every single person in this country a guarantee of high-quality health care. Everybody is covered. Nobody goes broke because of a medical bill. No more fighting with insurance companies. This is a goal worth fighting for, and I'm in this fight all the way.

There are other approaches as well I'm glad to see us put different ideas on the table.

So, we have a gesture toward #MedicareForAll. But then, Warren, instead of going into detail about how #MedicareForAll would work, immediately backtracks and emits a welter of detail about minor fixes improvements, on the order of "portability," "access," and reduced "managerial involvement." (Different details, but still details). Then she moves on to Massachusetts. Read this, and it's clear where Warren's heart is:

Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation[4].

That didn't just happen because we woke up one morning and discovered that insurance companies had just started offering great coverage at a price everyone could afford.

We demanded that insurance companies live up to their side of the bargain. Every insurer participating in our exchange is required to offer plans with standard, easy-to-compare benefits and low up-front costs for families. Last year, we had the second-lowest premiums in the ACA market of any state in the country. Massachusetts insurers pay out 92% of the dollars they bring in through premiums to cover costs for beneficiaries – not to line their own pockets.

The rules are tough in Massachusetts, but the insurance companies have shown up and done the hard work of covering families in a responsible way. We have more than double the number of insurers participating on our exchanges, compared to the average across the country. They show up, they serve the people of Massachusetts, and they still make plenty of money.

Look, we still have plenty of work to do, particularly when it comes to bring down health spending, but we're proud of the system we have built in Massachusetts, and I think it shows that good policies can have a real impact on the health and well-being of hard working people across the country.

Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it?

Warren Has No Coherent Theory of Change

Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope, but let's search on "rules" and see what we come up with. More from the transcript:

But it is policy, rules and regulations, that will determine whether workers have a meaningful opportunity to share in the wealth that is generated.

Here, workers are passive , acted upon by rules, and those who create them. But Warren contradicts herself: "Lyft and Uber have often resisted efforts of those very same workers." Here, workers are active. But if workers are active in the second context, they are also active in the first! Where does Warren think change comes from? The generosity of Uber and its investors? More:

Antitrust laws and newly-created public utilities addressed the new technological revolution's tendency toward concentration and monopoly, and kept our markets competitive. Rules to prevent cheating and fraud were added to make sure that bad actors in the marketplace couldn't get a leg up over folks who played by the rules.

Note the lack of agency in "were added." Warren erases the entire Populist Movement ! She also can't seem to get her head round the idea that workers didn't necessarily play by the existing ruies in order to create new ones. And:

Workers have a right to expect our government to work for them. To set the basic rules of the game. If this country is to have a strong middle class, then we need the policies that will make that possible. That's how shared prosperity has been built in the past, and that is our way forward now. Change won't be easy. But we don't get what we don't fight for. And I believe that America's workers are worth fighting for.

Now, on the one hand, this is great. I, too, believe that "America's workers are worth fighting for." What Warren seems to lack, at the visceral level, is the idea that workers should be (self-)empowered to do the fighting (as opposed to having the professional classes pick their fights for them). Here is Warren on unions:

Every worker should have the right to organize, period. Full-time, part-time, temp workers, gig workers, contract workers, you bet.

Very good. More:

Those who provide the labor should have the right to bargain as a group with whoever controls the terms of their work .

The idea that workers themselves should control the terms of their work seems to elude Warren. This erases, for example, co-ops. More:

Government is not the only advocate on behalf of workers.

"Not the only?" Like, there are lots of others? This seems a tendentious, not to say naive, view of the role of government. More:

It was workers [here we go], bargaining through their unions [and the qualification], who helped [helped?] introduce retirement benefits, sick pay, overtime, the weekend, and a long list of other benefits, for their members and for all workers across this country. Unions helped build America's middle class, and unions will help rebuild America's middle class.

Here, at least, Warren grants workers (partial) agency, but only through the institutional framework of unions . That distorts the history. Granted, "helped introduce" is doing a lot of work, and who they were "helping" isn't entirely clear, but the history is enormously complicated. (Here again, Warren needs to do the reading.) For example, the history of the weekend long predates unions . And "bargaining through their unions" isn't the half of it. Take, for example, the Haymarket Affair . From the Illinois Labor History Society:

To understand what happened at Haymarket, it is necessary to go back to the summer of 1884 when the Federation of Organized Trades and Labor Unions, the predecessor of the American Federation of Labor, called for May 1, 1886 to be the beginning of a nationwide movement for the eight-hour day. This wasn't a particularly radical idea since both Illinois workers and federal employees were supposed to have been covered by an eight-hour day law since 1867. The problem was that the federal government failed to enforce its own law, and in Illinois, employers forced workers to sign waivers of the law as condition of employment.

Fine, "rules." Which weren't being obeyed! More from the Illinois Labor History Society:

Monday, May 3, the peaceful scene turned violent when the Chicago police attacked and killed picketing workers at the McCormick Reaper Plant at Western and Blue Island Avenues. This attack by police provoked a protest meeting which was planned for Haymarket Square on the evening of Tuesday, May 4. Very few textbooks provide a thorough explanation of the events that led to Haymarket, nor do they mention that the pro-labor mayor of Chicago, Carter Harrison, gave permission for the meeting . Most speakers failed to appear . Instead of the expected 20,000 people, fewer than 2,500 attended . The Haymarket meeting was almost over and only about two hundred people remained when they were attacked by 176 policemen carrying Winchester repeater rifles. Fielden was speaking; even Lucy and Albert Parsons had left because it was beginning to rain. Then someone, unknown to this day, threw the first dynamite bomb ever used in peacetime history of the United States. The next day martial law was declared, not just in Chicago but throughout the nation. Anti-labor governments around the world used the Chicago incident to crush local union movements.

This is how workers "helped introduce" the eight-hour day.

Yes, America's workers are "worth fighting for." But they also fight for themselves , and are fought against! Warren's theory of change -- which seems to involve people of good will "at the table" -- cannot give an account of events like Haymarket or why, in the present day, it's Uber's drivers who are also the drivers of change, and not benevolent rulemakers. Warren's views on the social contract are in great contrast to Sanders' "Not me, us."

NOTES

[1] Warren is far stronger in areas where she has developed academic expertise than in areas where she has not.

[2] Google is Google, i.e., crapified, but if Warren has retracted or changed her views on Uber, I can't find it. She was receiving good press for this speech as late as August 2017 .

[3] Oddly, bankruptcy is where Warren made her academic bones. I'm frankly baffled at her lack of full-throated advocacy on this, especially before a friendly audience.

[4] Warren, by juxtaposition, suggests that Massachusetts' health insurance coverage causes it to be "the healthiest state in the nation." This post hoc fallacy ignores, for example, demographics and the social determinants of health .

[5] Warren focuses on health insurance, not health care. I'm nothing like an expert in the Massachusetts health insurance system. However, looking at this chart , I'm seeing all the usual techniques to deny access to care: Deductibles, co-pays, out-of-network costs, and (naturally) high-deductible plans. Health care should be free at the point of delivery. Why is that so hard to understand?


Burritonomics , January 20, 2019 at 5:16 pm

I quickly went over the (188 page!) report referenced in Warren's claim that "Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation". It should be noted I went in with the expressed purpose of finding something to be snarky about, and I found it.

One of the metrics under "core measures" of clinical care was Preventable Hospitalizations. As it states in the report itself: "Preventable hospitalizations reflect the efficiency of a population's use of primary care and the quality of the primary health care received Preventable hospitalizations are more common among people without health insurance and often occur because of failure to treat conditions early in an outpatient setting". Wow! With such bang up health insurance in MA, one would figure they would do great on this metric. Nope! MA ranks 37th in the country. Many more such examples can be found, I'm sure.

I have a real dislike of these "who's best" lists, regardless of topic. Rarely do they (the aggregated ratings) contain insight beyond that captured by the individual metrics.

lambert strether , January 20, 2019 at 5:24 pm

Massachusetts is #1 on mortality (though they have issues with opioids). They have median US age, so it's not the enormous Boston student population. So they're doing something right, I'm just not sold it's health insurance or, more to the point, health insurers. They do have more physicians (and psychiatrists) per capita.

Joe Well , January 20, 2019 at 8:52 pm

What is "mortality" in this case? I'm curious about this because people often casually say that US health outcomes are worse than in other countries by looking at life expectancy (which I guess is not the same as mortality), and that comparison is rarely done on a state by state basis in the US.

Massachusetts is roughly tied with the other top ten states in life expectancy, which are almost all "blue" states . Worldwide, life expectancy among highly developed countries is roughly similar, within a few years of each other . The US comes out towards the bottom (no. 31), but only by about 1-3 years.

Also amazed just now to see that Asian American and Latino life expectancy are so much higher than for white and black Americans. Does anyone know anything about that? I'm really stunned.

Usually, lower life expectancy for blacks is given as evidence of inequality, but the white-black gap (about 1-2 years) is tiny compared with the black-Latino and black-Asian gap, or for that matter, the white-Latino or white-Asian gap, which are more like 5-10 years. I'm really floored by that.

In general, looking at the numbers just now has shaken my assumptions about poor US life expectancy and also racial disparities and I'm wondering if I'm misinterpreting them.

Joe Well , January 20, 2019 at 9:10 pm

Wow, you learn something new every day.

Apparently there is something called the "Hispanic Health Paradox" that has been studied intensively for over 30 years . The biggest reason seems to be much lower rates of smoking. There also seems to be a filtering effect whereby healthier people migrate to the US. Anecdotally, I'd suggest much lower rates of alcohol and drug abuse, but the article doesn't mention that.

So, why Mass. has a relatively high life expectancy could in part be due to it having one of the earliest and most aggressive anti-smoking movements. I'm guessing historically high smoking rates (up to 50% of adults in the 1950s with huge second-hand exposure) could also account for poorer health outcomes today.

BoyDownTheLane , January 21, 2019 at 12:49 am

One of my favorite pictures (the one I have not yet taken) would have been an elevated shot of the intersection at Longwood and Brookline Avenues (379–385 Brookline Ave) at noon on a clear, sunny spring day to see the murmuration of medical staff running between appointments, lunch, rounds, etc.

The intersection is surrounded by arguably some of the finest medical institutions in the Western world (Beth Israel Deaconess, Dana-Farber, Brigham & Women's (where Atul Gawande, author of the book "Better" and the whole entire concept of positive deviance, once held court), Harvard Medical School itself with its etched-in-granite entrace to the Countway Library that reads "Ars Longa, Vita Brevis", and the Harvard School of Public Health.

The murmuration of white coats may be at that moment the greatest single concentrated density of medical excellence at one time. It is easy to scoff. I've been the recipient of bad medicine myself, but also far more high-quality, life-saving medicine. But the public health movement in Massachusetts has been around for a very long time and is supported by and engrained within governmental regulations, oversight and policy. Insurance plans covering most of the state ranked, typically and for years, #'s 1, 2, 3 and more. The Healthcare Effectiveness Data and Information Systems report out results that are painstakingly gathered, audited to improve performance. It is fair to say that a major part of the intersection between computing and medicine was born and is overseen across the river in Cambridge. Organizations that collect or audit data for health plans and providers are screened, trained and certified by NCQA ( https://www.ncqa.org/about-ncqa/ ).

In addition, there are national, regional and state associations devoted to quality improvement and toi improvement of access. The National Association of Community Health Centers (those clinics funded Federally to serve the under-served for free or on a sliding scale) "works in conjunction with state and regional primary care associations, health center controlled networks and other public and private sector organizations to expand health care access to all in need." There are CHC's dotted everywhere around the country (albeit not enough of them), and there is a state association in almost every state. No one can ever be turned away from a CHC, especially for lack of ability to pay; the Federal government underwrites their care.

nothing but the truth , January 20, 2019 at 5:29 pm

govts can call force us to call toilet paper a pound, but i doubt they can make it worth a pound of sterling silver – if they pretend that they can produce any amount.

Brooklin Bridge , January 20, 2019 at 5:58 pm

Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ) and particularly her whole rant on the superlatives of Massachusetts insurance care (that means, care for insurance companies) , increasingly neglects health and people care as the primary concern of medicine and the people who practice it.

As an average Joe, meaning not part of the medical world, I have come across a surprising number of doctors in both social circumstances as well as health issues of my own and of my extended family, where doctors have complained about the ever worsening constraints imposed on them by insurance companies. I know at least three doctors who retired early because of it and one of them talks about it being a significant problem in keeping highly qualified doctors in general practice. From ever more ridiculously short visits, to constant refusal to cover such and such a drug, to all manner of schemes to improve patients health by overseeing and controlling what the doctor does to finding ways to monitor what the patient does; what he or she takes as medicine and exactly when and how often – cutting the doctor out of the loop completely. Improve the patient experience my *ss. It's horrible and it all comes down to ever new ways to reduce coverage – to make more money.

Perhaps I'm being a little unjust, but Warren seems fine with this "system" where the gate keepers make, "plenty of money," as long as people are going in and out of doctors' offices in countable droves as if on run-away conveyer belts. I should at least allow that many of her superlative claims are accurate (or somewhat accurate) and that there is fairly wide coverage in this state but nevertheless stress that our excellent medical facilities in Boston proper are due to historical reasons and NOT to RomneyCare.

deplorado , January 20, 2019 at 5:59 pm

Thank you Lambert, for your cogent and discerning analysis as always. I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference.

What worries me more though is Sanders's bill and why he wouldn't go all the way? Would you do an analysis of that please – will really appreciate it.

Thanks!

Joe Well , January 20, 2019 at 6:10 pm

The vast majority of Massachusetts health plan providers are nonprofit HMOs so I'm baffled by the idea that they are making tons of money since legally they are not supposed to.

The most obvious difference between Mass and the rest of the country is precisely the preponderance of nonprofit health plans (it's not commonly called health insurance here) and nonprofit hospitals. The idea of for-profit health plans and hospitals freaks me out.

It's worth noting that Mass health coverage seems to have gotten worse in recent years, though I don't know how much of that is due to Obamacare. High deductibles, coinsurance, confusing in-network requirements combined with poor documentation and even poorer customer service to tell you what is in-network and what is not. I just got a surprise $370 bill for a provider that supposedly was out of network even though I had checked extensively that they were in-network. That is the first time that has ever happened to me in Mass. Not to mention the confusing and unnerving notices I got the last few months saying I was in danger of losing coverage. A great big ball of Weberian beaureaucratic stress.

bob , January 20, 2019 at 8:04 pm

Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin.

somecallmetim , January 20, 2019 at 10:08 pm

Health Care Economist / Professor Uwe Reinhardt used to comment that in the current system non-profit hospitals (The Sisters of Mercy, with a token nun on their board, in his telling) were subject to the same forces as for profit hospitals.

He also said Massachusetts has the only adult health care system, and the other states are all adolescents.

johnnygl , January 20, 2019 at 9:10 pm

We've got for-profit hospitals Cerberus took the caritas network. The hospitals dominate this state. The rest of us are just living here.

johnnygl , January 20, 2019 at 9:15 pm

Special thanks to the catholic church for selling such an important institution to a monster that guards the gates of the underworld.

I bet it was to cover the costs of child predator priests.

Joe Well , January 20, 2019 at 10:20 pm

Wow, I'd missed that (moved out of state, then came back). Thanks for the update. It looks like the Catholic Church (former owner of Caritas) has further enhanced its legacy in Massachusetts. However, I believe it is still true that the hospital market in Mass. is dominated by nonprofits (albeit greedy nonprofits).

And yes, hospitals and hospital chains (e.g., Partners Healthcare, which is nonprofit) pose huge challenges to managing healthcare costs in Mass. as the numerous Boston Globe investigative series attest, by using their market power to raises prices.

My concern is when the market becomes dominated by for-profit actors, the profit-seeking, which is already bad with nonprofits, becomes even worse, especially in an ultra-expensive market like Greater Boston.

Brooklin Bridge , January 20, 2019 at 6:16 pm

I should add (if my earlier comment get's posted), it's even more surprising how many doctor's seem just fine with all the negative changes being brought about by insurance companies' intrusive quest for control and I don't mean just the ones who say nothing.

That is, some doctors seem to enjoy the vestiges of the glow of community respect and honor that once went with being a doctor all while doing almost nothing other than sheep herding patients through the office in good file while staff (not the good doctor) attend to making the visit digital and storing it away in some cloud.

Tomonthebeach , January 20, 2019 at 7:07 pm

I agree with Warren Mosler that Elizabeth Warren's apparent ignorance of MMT, much less mastery of it, makes here a lame candidate in my book. She needs to get woke pretty quickly or settle for some cabinet appointment.

Anarcissie , January 20, 2019 at 10:10 pm

Is MMT now Scripture?

ChrisAtRU , January 20, 2019 at 10:22 pm

It's more important than 'scripture' it's how sovereign fiat money actually works .

Joe Well , January 20, 2019 at 10:57 pm

You don't even need MMT. When asked how the federal government can pay for something, people can just answer, "the same way we pay for military and intelligence spending." Any politician who won't say at least this is deeply suspicious.

David in Santa Cruz , January 20, 2019 at 7:40 pm

In The Unwinding , George Packer quotes Elizabeth Warren as describing her political views thusly:

"I was a Republican because I thought that those were the people who best supported markets"

I'm glad that she's out there, I'm glad that she's talking, and we need an open and transparent nomination process, but Bernie Sanders remains the only (potential) nominee who comes close to representing my views. Good piece.

emorej a hong kong , January 20, 2019 at 7:50 pm

The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech).

The speech's date (May 19 2016), was two days after Bernie won the Oregon primary by 14%, and two days before Hillary won the Washington state primary by 5%.

Synoia , January 20, 2019 at 8:07 pm

It was going to be BS directly after this:

New America (board chair emeritus Eric Schmidt

The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist.

Synoia , January 20, 2019 at 8:11 pm

It was going to be BE after this phrase

New America (board chair emeritus Eric Schmidt,

The Eric Schmidt who took Google doen the path of spying on everybody. He has nothing to offer by centrist rhetoric. It would be very interesting in how much In-Q-Tel invested in Google.

flora , January 20, 2019 at 8:39 pm

Thanks for this post.
And thanks for the reminder that the 8 hour workday and the 40 hour workweek were not 'given' to workers, they were won by workers.

Matthew G. Saroff , January 20, 2019 at 9:48 pm

I made an a similar observation on my blog .

Compare these two quotes on Pharma looting.

Warren:

Giant companies may hate my Affordable Drug Manufacturing bill – but I don't work for them. The American people deserve competitive markets and fair prices. By fixing the broken generic drug market, we can bring the cost of prescriptions down.

Sanders:

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them.

This is a not an insignificant difference

Mike Barry , January 20, 2019 at 10:30 pm

The best is the enemy of the good.

Yves Smith , January 20, 2019 at 11:17 pm

Tell me what about Warren not understanding how federal taxes work, which is fundamental to formulating sound fiscal policy and spending plans, not being serious about fixing our health care system, or praising the predatory gig economy, is "good".

RepubAnon , January 20, 2019 at 11:32 pm

On a side note: self-employed workers pay more out-of-pocket into Social Security than W-2 employees. W-2 employees only pay half the Social Security tax – employers pay the other half via a "payroll tax."

The self-employed pay both the employee's half of Social Security, and also pay a "Self-Employment tax" (the employer's half of Social Security). The logic is that if you are both employee and employer, you should pay both halves.

Yves Smith , January 21, 2019 at 12:58 am

This is thread jacking, plus an economist would point out that the employer clearly is paying a net wage that reflects his awareness that he is paying the employer side of the FICA taxes.

Ape , January 21, 2019 at 12:31 am

Or lesser of two evils? There really needs to be a good discussion again about reform versus structural change without Chait-like pretensions. The question isn't just whether we'll get there in time, but whether reform even out runs reaction. Once you take out patriotic myth, it's not obvious whethervthe good in the long term is even worth bothering with.

Glen , January 21, 2019 at 12:47 am

Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won.

The Rev Kev , January 20, 2019 at 11:01 pm

I can't help but think that if you are talking about the "Next Social Contract", them you should put something in there that if you have children going hungry then something has gone wrong with your society. Not being snarky here as I believe that a fundamental purpose of society is to protect those in need. An earlier society talked about 'women and children first' and they were not too far off the mark here.

She was invited to talk about the gig economy but in reading her speech I was under the impression that she wants the Federal government to underwrite the costs of workers for corporations to ensure that maybe these workers have food to eat while working for these very same corporations. I suspect that this is the thinking behind letting Amazon workers go for Federal assistance for the sheer basics of life while Amazon makes off like bandits.

No. The way to go is to enforce corporations like this pay a living wage and not to have them count on the country to make up the difference. If they start to protest, then start to talk about looking over their accounts for any discrepancies to make them back off. That's how they got Al Capone you know. Not for being a gangster but for not paying his taxes while doing so. And do the same for mobs like Uber and Lyft and all the other corporations.

BoyDownTheLane , January 21, 2019 at 12:16 am

" Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives ."

http://sultanknish.blogspot.com/2019/01/why-no-one-likes-elizabeth-warren.html

Left in Wisconsin , January 21, 2019 at 12:38 am

Sigh. Nail hit squarely on head. The one thing I will say to Warren's credit is that she has learned in some specific ways that the world isn't invariably the pure meritocracy that is so instinctively part of her world view. That said, it seems clear there will always be plenty that she is simply not capable of seeing, so she will always say and support things that are just wrong. She will not be leading the revolution.

[Jan 19, 2019] Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market

Jan 19, 2019 | economistsview.typepad.com

anne , January 15, 2019 at 05:59 PM

https://prospect.org/article/three-bernie-sanders-bills-arrest-highway-robbery-prescription-drug-market

January 14, 2019

Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other nations pay -- all good options
By DEAN BAKER

The prescription drug market in the United States is an incredible mess. From an economic standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free market often sell for tens or even hundreds of thousands of dollars because we give their manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that would be expected from tariffs as high as many thousands percent.

From a heath perspective the situation is no better. The huge markups give drug companies enormous incentive to misrepresent the safety and effectiveness of their drugs and to push them for uses where they may not be appropriate. This is a big part of the story of the opioid epidemic.

Cumulatively, it is a huge deal in both economics and health. We spent more than $430 billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have cost less than $80 billion in a free market. The difference of $350 billion is almost five times the annual federal budget for food stamps. This is real money.

This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising cost of prescription drugs. The three measures provide alternative paths for reducing drug prices.

The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for any drug that sold for a price exceeding the median price in five other major countries: Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since drug prices in these countries are roughly half as much as in the United States. Drug companies would have a choice of either lowering their prices or losing their patent monopoly.

In the latter case, the competition is likely to push the price well below the levels in the five countries. While these nations do regulate drug prices, patent monopolies still let the companies charge a price that is far higher than the price that would exist in a competitive market with generic competition.

The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug insurance. Since this program spends roughly $100 billion annually on drugs, it should have serious bargaining power.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce Committee, which structured the Medicare prescription drug legislation, resigned immediately after the bill was signed into law to become head of the pharmaceutical industry's trade association.

The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an effort to take advantage of the fact that drugs are so much cheaper in other countries than in the United States. This bill would allow people to freely import drugs from other wealthy countries that have safety standards that are comparable to those in the United States.

This bill both highlights the sharp differences in prices between the United States and other countries and calls out one of the big lies used to justify these differences. Allies of the drug industry often claim that we cannot count on getting safe drugs from other countries, implying that countries like Canada and Germany do not protect their populations from unsafe drugs.

This is, of course, absurd. The standards in these countries are every bit as high as in the United States. And, if we think the quality of imported drugs is a problem, we all should already be very worried because many of the drugs and ingredients in drugs sold in the United States are already imported, largely from China. So the idea that we can't be assured of the safety of imported drugs is simply an industry talking point, not a real concern.

Which of these paths for reducing drug costs is best? Importation is probably the most far-reaching, since it should quickly bring our prices down to the level of other wealthy countries. As a practical matter, however, progressives should back anything that moves the debate forward.

We really need to turn the industry on its head, paying for research upfront and then having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for research that has already been done, at the point when people are suffering from serious conditions jeopardizing their health or their life.

No one thinks it makes sense to pay firefighters based on the value of their work when they come to our burning house with our families inside, yet this is essentially how we pay for drug research under the patent monopoly system. In fact, the story is even worse with drugs, since typically we have a third party payer (either an insurance company or the government) who we are trying to get pick up most of the tab.

These bills would not fully solve the problem, but each would be a big step in the right direction. Sanders, Cummings, and Khanna have done a great service in pushing them forward.

mulp -> anne... , January 16, 2019 at 04:33 PM
"No one thinks it makes sense to pay firefighters based on the value of their work ..."

We value fire fighters as worthless, by not paying most fire fighters in the US.

After all, requiring the people saving your life to be paid kills jobs, so we end up with unpaid life savvers.

We should appply the same principle to people providing life saving food, the people building the roads needed to deliver life savings, the people making the vehicles used by those providing life saving services.

In fact, no one should be paid to work! Thats free lunch economics!

Sarcastic, yes.

Dean Baker meantioned nothing about costs, which are always labor costs.

Look, Keynes argued that when there were unemployed workers, and capital is scarce, government should tax and spend to pay workers to build capital.

For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs developed, the private capital in drug factories, etc will produce so many drugs that drug prices fall to total labor costs per unit, plus the drug tax.

We know there are unemployed drugresearchers because NIH always runs out of money to pay all thre recent collage grads seeking grants to fund their hoped for job as a researcher.

Plp -> mulp ... , January 18, 2019 at 01:41 PM
Mulp what about monopoly profits my friend

Research could rise and marketing cuts pay for it

Yes there's slack created
In marketing jobs and funding entertainment of course

Plp -> anne... , January 17, 2019 at 08:40 AM
Bernie and Liz are too valuable to waste running for
The Dem nom

Leave that for a clever weather vane
Like Harris and that jersey senator

The gal from the Bronx
is another Bill Bryan

She is the future

anne -> Plp... , January 18, 2019 at 09:21 AM
The gal from the Bronx
is another Bill Bryan

She is the future

[ Funny and right and especially clever. ]

Julio -> Plp... , January 18, 2019 at 09:21 AM
Agreed completely.
Warren, in particular, makes a great senator but I doubt would make a great president.
Christopher H. said in reply to Julio ... , January 18, 2019 at 10:01 AM
Disagree, unfortunately in the American system the President gets all the attention and can spread the message.

Either Bernie or Warren would be good. I'd much prefer Bernie.

Plp -> Christopher H.... , January 18, 2019 at 01:43 PM
No problem if they win the POTUS job

Still I'd prefer AOC

[Jan 13, 2019] Libertarian wet dreams and reality of the Us healthcare

Jan 13, 2019 | www.nytimes.com

JB Nashville, Tennessee Jan. 11

@Bill - So you're willing to gamble with your own health and the well-being of any family or loved ones you have and trust in some ambulance chaser against an armada of $3000 suits? Good luck with that.

While I'm often skeptical of our government, I have ZERO faith in any corporation to do right by me.

Their only mission is to make as much money as they can, and even paying out the occasional lawsuit is a reasonable cost of doing business. The only way a capitalist entity can be trusted is if a more powerful authority is looking over their shoulder. The FDA is one of many federal entities standing between us and an indifferent group of shareholders and CEOs.

[Jan 11, 2019] Health Insurer Greed or Desperation An Odd Data Point From Cigna naked capitalism

Notable quotes:
"... It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not. ..."
"... The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home. ..."
Jan 11, 2019 | www.nakedcapitalism.com

Health Insurer Greed or Desperation? An Odd Data Point From Cigna Posted on January 9, 2019 by Yves Smith I sometimes give personal Consumerist-type anecdotes about dodgy vendor behavior in case readers have had similar experiences.

Admittedly, health insurers being difficult about paying claims is so common that they fall in the realm of "dog bites man" stories. But the elements of my latest arm-wrestle with Cigna suggest that the insurer is so eager to maximize profit and burnish its financials that it is doing the equivalent of pulling up the sofa cushions to collect change.

I've had this plan a very long time, since the early 1990s. Cigna in theory has not changed the terms (to do so, it would have to notify me and New York State) save approved rate increases. In practice it has, by among other things a few years back requiring that claims be submitted within 120 days of service. That has allowed it to engage in a new form of mischief: simply not processing some claims. No doubt the hope is that consumers won't notice, or will notice too late to get duplicate documentation and resubmit before the 120 days are up.

Mind you, for well over 15 years, I never had a single claim go astray. Now it happens with sufficiently high frequency for it to be implausible that the US Postal Service is losing so many of my letters, when other envelopes virtually never go missing. So every time I submit a claim, I have taken to recording the details necessary to locate the items in Cigna's system, as well as the mailing date.

Last July, Cigna sent a letter about a "pharmacy claim". It was a remarkably content-free document, with no reference to dates of service or any clues to allow a customer to figure out what they might be referring to, particularly since I do not have a pharmacy plan. A "pharmacy plan" is when the doctor sends a scrip to the pharmacy on behalf of a patient, and the pharmacy bills the insurer, with the patient responsible for any co-pay. My plan covers prescription drugs, including ones I get overseas (I've submitted prescription drug claims from England and Australia). I pay for the drugs and I submit for reimbursement. And until the mysterious July letter, I never had any problem with them being paid (provided, of course, Cigna didn't try claiming it had never gotten the claim).

Fortunately, because I keep good records, I could see I had sent in a claim in late June for four dates of service for less than $400 worth of meds total. The only reason the amount was that high was three of the four items were 90 day supplies.

I called Cigna and got a rep who found the four items and confirmed they were in a payment limbo and ought to be paid.

When no check had arrived by September, I called again, had the agent say that there was not reason for the claim not to have been paid, and put it in for reprocessing.

On November 28, with still no payment, I insisted on speaking to a supervisor, which it took an ungodly amount of time to reach. I started making noise about external appeal to New York state (my plan is a New York state regulated plan). She confirmed like everyone else that it should have been paid, and said the check would go out in three to five days.

Two weeks later, nothing from Cigna.

I called again. I got an agent who said the payment is pending.

By this time, steam was pouring out of my ears. I asked again to speak to a supervisor. After a 30 minute wait, I was told one would call me back. I should have known from long experience with Cigna that promises to make calls or follow up are empty, as this proved to be.

I decided to have one last go on the phone before writing the state for an external appeal. I called over the weekend. The agent said that the payment was issued on January 3, but she saw only three of the four drugs in the scans of the claims. Mind you, this was the cheapest scrip, and a shortfall versus what I should have received of about $13 (assuming that check finally arrives). But this is what this incident says about Cigna:

1. Recall that on the first call, and if my recollection serves me right, on at least one of the later calls, I confirmed the dates of the claims. The one that disappeared was the most recent in the date range, making it almost certain that I cited it most if not all calls.

This strongly suggests that the original Cigna hope was that I would not follow up adequately on their bafflegab letter, and when I did, someone went and scrubbed my record to reduce the amount Cigna would have to lay out. This is such a small amount that it would seem hardly worth the effort .which further suggests that Cigna has this sort of records-doctoring highly enough routinized to be able to do it cheaply. 1

2. Cigna has supposedly initiated payment right after the new year. Even though Cigna ought to be on an accrual as opposed to a cash accounting basis, it's not hard to infer that they kicked the payment back into a new fiscal year to flatter some sort of metric. It might not even be a financial reporting metric but some other measure that senior management and/or analysts follow.

As we said at the outset, in terms of abuses, this is small beer. But that's the point. Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me, knowing in this era when class action suits are virtually dead, that they can grift with no fear of being held to account.

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

____

1 The last agent checked my records for the date of the gone-missing drug claim to see if it had somehow gotten separated from the other three and was being handled separately. She came up empty-handed. Recall that I now have a not-approved, not-noticed-as-required change to my contract of a 120 day submission limit, so disappearing that item so late in the game makes it impossible for me to resubmit that item.

Geo , January 9, 2019 at 4:09 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Well said. You're much more thorough and persistent than I am. I'm their target dupe that won't notice such things and just accept that it was my fault when I do notice. Very insightful read. Thanks so much!

WestcoastDeplorable , January 9, 2019 at 3:17 pm

Sorry to read of your problems, but Insurance companies aren't the only category screwing with the details; I recently transferred a balance to U.S. Bank on one of those "zero interest for 12 month" deals. In about 2 months after the transfer, all the sudden I get a late notice from them, then realize I didn't receive a statement (which was about 10 days late). And they laid a $39 charge on the account, which I was able to get waived with a trip to my local bank. Little did I realize this "late pay" also resulted in nixing the "zero interest" deal, and they levied the full interest on the balance.
Needless to say, I transferred the balance elsewhere, but seems to me lots of companies are gaming the mailing of statements to pad their coffers.

campbeln , January 9, 2019 at 3:53 pm

I had a good one with Macy's we bought a ton of stuff for the new house back here in the US and got the 0% interest for 12 months on their credit card for the first purchase or some-such. What the lady at the counter did was to run 2 separate transactions on the card so the second, much smaller, transaction fell outside of the "first purchase" and incurred the minimum monthly interest charge. Over the course of the 12 months, I'd have been in a slight deficit thanks to these additional charges, so I paid the damned thing off in full and threw it in the drawer.

So Macy's went from having a part-time AmEx card user to one that never uses it all because they didn't want to uphold their own promo Picking up pennies in front of a steamroller

Barbara , January 9, 2019 at 5:55 pm

Some years ago, I got such a 0% offer from a bank which issued one of my credit cards. This one was for existing debt and lasted until the debt was paid off. I was happily paying off my debt in reasonable monthly installments. After I paid my 6th monthly installment, I got a letter from the bank saying that they needed to raise the interest rate and would appreciate if I would concede. They added that if I continued to insist on 0%, as was my right to do, my credit card would be discontinued on the last payment. I chose to continue the 0% deal and, as promised (the only promise they kept), my credit card was cancelled thereafter.

Fast forward several years, I regularly get credit card offers from said company. Needless to say, I don't think much of people (or businesses – corporations are people too!) who renege on deals. You can guess what is not in my wallet!

The Rev Kev , January 9, 2019 at 4:18 am

Excuse for for asking but just to clarify a point. When you send mail to Cigna and you say that you record the details, are you talking about certified mail and registered mail then? The reason that I ask is that by using the same in Oz, it has saved both my daughter and I individually over a thousand dollars each when the recipient tried at first tried to deny receiving what we sent until confronted with tracking numbers that can be checked online.

Arthur Dent , January 9, 2019 at 9:15 am

More and more I am going to tracking numbers with signature required for things that have any sort of value.

The joy of focusing on shareholder value is that all other stakeholders are subservient to it. Ultimately, the sheer greed of the corporations is likely to force the general population to demand a government-run single-payer system where at least they can vote the politicians out of office instead of having unaccountable executives making their lives miserable. The inability to repeal the Affordable Care Act was just the first shot across the bow.

Spent more time in Canada over the past few weeks. Everybody I spoke to up there is utterly baffled by what is going on in the US and is seriously wondering if the US is officially insane. They cannot understand why we continue to live down here. BTW – many of these people are white people over 50 with military backgrounds and little to no college in the demographic that would have been probably voting for Trump in the US.

Octopii , January 9, 2019 at 1:05 pm

Have considered moving but they don't want us up there.

Yves Smith Post author , January 9, 2019 at 9:44 am

It takes $3+ per envelope to send something certified and a half hour tax on my time to go to the post office.

And sending a letter certified does not prove what was in the letter. It's useless from an evidentiary standpoint. Cigna could claim the envelope had no claims in it, or that the claims were "unscannable" (another "dog ate my homework" they've tried now and again). It's useless in proving a submission.

monday1929 , January 9, 2019 at 4:22 pm

Yves, you might try video-taping the mailing process, including video showing the papers as legible etc as they are sealed in envelope and handed over postal counter and showing tracking numbers.
Include in the envelope a letter explaining you will post video on you-tube if they claim "unscannable" or that envelope was empty.
United Healthcare broke dozens of promises to "call back"- they never ONCE did so. Hopefully not to far off topic, I would like to keep NC updated on current complaint with NY Office of Professional Discipline regarding a dentist who possibly hid about 100 bad (as in semi-criminal) Yelp reviews by establishing a phony company name and shifting reviews there. So far, after one month not a peep from Port Chester regional office where referred to.

beth , January 9, 2019 at 7:35 pm

Alert to United Healthcare Medicare Supp. retirees. I'm sure the UH did this not just to me but to all of those who carelessly pay all bills sent to them. When I signed up for AARP United Healthcare insurance, the rep told me that he would have to accept a check for the first month and then had to put me on a ckg acct withdrawal plan. I had never done that before and didn't like the idea. It turned out that that saved me in the long run for two reasons. First they billed me for the first month after accepting my check. I did not pay it and by the time I received it they had already taken money out for the second month. I am sure there are many seniors who just paid the bill anyway. Slick trick & sick trick.
And then a year later I was finally diagnosed with my genetic disease after all these years. I began getting the only medicine specifically for this disease which since it is an orphan drug is expensive. They rejected the first bill from the provider and told them I was not a member of the plan. I was thrilled that I had had the money taken out of my acct. so they could not say the check was late.

Kradek , January 11, 2019 at 12:25 am

Why won't these companies let us email the claims? Cheaper for all, content and dates verifiable

run75441 , January 9, 2019 at 11:00 pm

Yves:

Green Card works in court and I have used it with Ocwen

flora , January 9, 2019 at 11:17 pm

By 'green card' do you mean the usps certified return receipt green card?

vlade , January 9, 2019 at 4:33 am

Hmm.. I haven't seen "the cheque will be issued" excuse for ages now, courtesy of pretty much all European payments being direct and settled on T+1 latest.

I guess having netflix and Facebook (the "great innovations" coming out of the US) is more important to a number of US residents than a working payments system like say the EU has.

mle detroit , January 9, 2019 at 10:12 am

I've been trying unsuccessfully to decode your first sentence. What is this payments system, where can a neophyte learn about it, does the UK use it, and what how Brexit affect it?

Kpl , January 9, 2019 at 4:36 am

When bad behaviour and fraud go unpunished this is what one should expect.

Disturbed Voter , January 9, 2019 at 5:27 am

Stick to your guns, and make them meet your business performance metrics!

Heath insurance is inherently un-profitable in the long run, unless service is denied.

oh , January 9, 2019 at 3:58 pm

Not really. Denial of claims is yet another way for them to pad their profits.

Louis Fyne , January 9, 2019 at 6:32 am

cigna bought express scripts and the deal closed in december.

it could be cost-cutting-induced incompetence. it could be intentional revenue padding. could be both.

and ya, compared to the daily/weekly neoliberal microaggressions, no wonder why after 3weeks a lot of people shrug when it comes to the government shutdown

Spring Texan , January 9, 2019 at 11:06 am

Love your phrase "neoliberal microaggressions." We need to start using that more!

Very descriptive.

rd , January 9, 2019 at 12:22 pm

This government shutdown is going to get very interesting as the Trump Administration tries to expand what are "essential services" requiring workers to come in without pay. So far it hasn't interfered with my travels because the TSA and ATC workers are all there working without pay. I believe tax refunds are going to be declared "essential" so those workers will be called back to process them without pay. This will likely be occurring in numerous other areas as the Administration gradually discovers that government workers actually do something.

Thad Allen had an interesting interview on NPR this morning as he discussed the Coast Guard working without pay: https://www.npr.org/2019/01/09/683501454/coast-guard-members-may-have-to-work-without-pay-during-shutdown

The GOP may have finally figured out how to pay for tax cuts: you still provide the services but you don't pay the workers!

Octopii , January 9, 2019 at 1:08 pm

Reminds one of the old Soviet saying, "They pretend to pay us and we pretend to work."

ambrit , January 9, 2019 at 1:10 pm

This dynamic is beginning to resemble the joke attributed to Lenin. "The Capitalists will sell us the rope with which we hang them."
I cannot think of a better way to energize a general strike than this.

Oh , January 9, 2019 at 4:02 pm

The TSA is just a pretend act anyway. It's all for show.

Larry , January 9, 2019 at 7:01 am

Perhaps the plan is to fatigue customers over small amounts to condition them to give up appeals over larger disputes.

Homard Mard Hankee Ospetsua , January 9, 2019 at 7:05 am

For most of the year 1982, I worked as a parlegal for a workmen's comp law firm representing petitioners (the sick or injured workers). Almost all of the cases we handled were from workers whose disability checks had stopped after six weeks. Always six weeks. That's the point at which the insurer would stop sending the checks and the worker would call us. Then, someone (like me) from the law firm would call the insurer. There would be one of a a stock set of about half a dozen responses, ranging from "my desk is so messy haha, but I know I saw that check in these papers somewhere" to "we don't have the proper medical documentation" (even though of course there needed to be medical documentation for them to send the first 6 weeks' worth of checks). After one or two phone calls from us, the checks would begin to flow again in a week or two (including checks for any week that the insurer had missed).

Oh, and 95% of these cases were from workers whose first language wasn't English.

The theory of the folks who'd been at this business for awhile was that, by having a built-in delay at the six-week mark, the insurers were making a little extra interest.

cnchal , January 9, 2019 at 7:17 am

> . . . in terms of abuses, this is small beer . . .

Tens of millions of small beers ends up being a gigantic vat of beer for Davos Man running Cigna. This is the result of Davos Man purchasing laws to prevent class action suits, which was paid for by stealing small beers from the peasants for decades.

I do pity the human capital at Cigna. Their worth to Davos Man is how well they steal small beers, the more they steal the higher in the organization they go, aspiring to be the next Davos Man.

Brenda Pawloski , January 9, 2019 at 8:33 am

If you are able to send your pharmacy claims online and keep an electronic copy, you can resubmit easier, faster and more often. I have done this with Cigna. I agree it is odd how they choose to ignore random claims, but it happens enough that it seems to be intentional.

BRUCE STONE , January 9, 2019 at 8:36 am

Have you tried sending the mailed correspondence by priority mail? Like Certified Mail–you get a tracking number– and documentation of delivery–but it's half the cost and my insurer will routinely refuse to accept certified mail to the claim's PO box number.
They can't refuse to participate in the priority mail tracking systems -- and it's as good in court as certified mail–although it does lack the signature credo from return receipt.

Also–my insurer routinely loses my docs and has a similar time limit on claims–but I have successfullly re-submitted based on documenting the previous sent item and the tracking data from USPS–most such systems require them to accept a resubmit when you can prove you sent it within the timeframe .

Yves Smith Post author , January 9, 2019 at 9:47 am

See the comment above. Won't help. Only proves I sent a letter in, not what was in the letter. They can say they got the earlier letter but the claim was not in it or was unscannable.

Questa Nota , January 9, 2019 at 8:54 am

Expecting reimbursement is a pre-existing condition and is not covered by the Plan for which you have eligibility. Refer to paragraph x.xx in section q.qq of user agreement #.##.

Yves Smith Post author , January 9, 2019 at 9:48 am

Not germane. Please don't offer irrelevant comments.

Kiwi , January 9, 2019 at 10:35 am

The comment was a joke

mle detroit , January 9, 2019 at 10:17 am

Good one, QN. Hope you didn't get scorched when you poked the Dragon.

RMO , January 9, 2019 at 4:39 pm

"You've chosen the 'never pay" plan option which clearly states (in this microdot that also serves as a period at the end of paragraph 4) that no claims you make will be honored. It's a good choice if you never get sick. Oh I hate to see a grown man cry Rev So get out of my office!" (adapted from the Pythons)

beth , January 9, 2019 at 7:40 pm

Do I sense a little hostility? Maybe you can be more explicit with what you are angry about.

Medical Quack , January 9, 2019 at 9:25 am

Well I gave a speech last year to a big doctors group about a lot of this and have written about it for years, it's called the Healthcare Algo Cartel. What folks can't see and don't want to believe is that there's tons of quants (called non traditional actuaries in healthcare) modeling policies and finding new areas every day where coverage for certain items can be "scored" to reduce the amount the insurer will pay.

I just don't know how long you all want to keep living in virtual perceptions and not realize this has been going on for years, just like the stock market, algos and their query results are running everything, and folks are too busy on Facebook or screaming at a box (Alexa) to take time out and learn up. Cigna is basically emulating United Healthcare and using the same models, but they don't own a PBM like United does or they don't own a bank like United does (an industrial bank). That bank by the way holds a lot of HSA money and United a couple years ago bought all the Wells Fargo HSA accounts, that's how they grow.

Nobody mentions an exit fine either for Cigna and Express Scripts. There's 5 years left for Cigna to be required to OptumRX as a PBM, contract signed with Catamaran, which OptumRX bought. Those folks with OptumRX as their PBM with Cigna have 5 more years before a switch to Express Scripts can be facilitated unless Cigna takes out another bond sale to pay it off.

People need to learn up and see what's going on, insurers are big data people and nobody seems to get that but just hang around long enough and more will come out about United Healthcare and what they and Apple are doing together, you already have United pimping Apple watches and all Apple employees are given an Optum Bank HSA account with one scratching the others back already.

Cigna by the way has Express Scripts hitting the big coupon savings route to compete, you can search that one up. Did you know that if you use a coupon to save money on your RX that that money can't be applied against a deductible? Time to learn up folks and see what the healthcare algos are doing, they're denying your care and access and there's more MBA quants on their way to be hired at insurers to model even more ways to profit by "scoring" consumers into oblivion, it's how you don't qualify done by queries and predictive models. The more complex they make it, the more insurers profit off of consumers not understanding the game and we don't have the ability to fight back (we don't have the algos and computer code).

Kris Alman , January 9, 2019 at 12:21 pm

The Cigna-Express Scripts merger is brilliant financial engineering to further consolidate insurance companies with PBMs in the fight between them and PhRMA over price gouging.

The coupons that you can get through Good Rx is a scheme of Express Scripts. https://www.biopharmadive.com/news/express-scripts-goodrx-roll-out-cost-savings-program/442197/

Now that Trump has signed bills lifting pharmacist 'gag clauses' on drug prices, the pharmacist can point you in the direction of drugs cheaper than your co-pays, which you pay-out-of-pocket and can't claim toward your deductible. What a win for Cigna/ExpressScripts!

Yves, I can't believe you have been so patient with Cigna! Complain to your insurance division. Though, I will add that while this may work at the individual level, it does nothing to create systemic changes.

JerryDenim , January 9, 2019 at 12:48 pm

Sorry to be so dense, but can you elucidate a bit more on "scoring" and how health insurance companies are using your personal data they've purloined or surreptitiously obtained to deny care? If you're not self-insured but receiving subsidized insurance through an employer plan are you still affected by "scoring"?

I would never knowingly register any health monitoring device with a health insurer or employer and I've always thought those who do are foolish, but recently I was considering buying an Apple Watch solely for the express purpose of being able to surf while being on call for my job. I believe there may be other waterproof, cellular-enabled wrist devices in the consumer space now besides Apple, but they all seem to be equipped with health monitoring sensors as well. I would never voluntarily register such a device with any programs in exchange for discounts, but it seems like linking a watch/wrist-phone to my cell phone account would be an iron identity shackle. I would really like a tiny robust cell phone reciever to screen calls while I'm in the water, which has the ability to increase my quality of life, but I don't want my heart rate and vitals logged and sold. I modified a song lyric a couple of decades ago to coin my own phrase; "Never mind what you're buying, it's what you're selling" – It becomes more true each passing year.

jfleni , January 9, 2019 at 9:31 am

RE: Health Insurer Greed or Desperation? An Odd Data Point From Cigna.

The "Nitty-gritty" A Scam wrapped in a Swindle, with a Fraud right on top!
Run -do not walk – to Medicare for ALL!

jefemt , January 9, 2019 at 9:58 am

Not fun to do the work, but imagine a few million Cigna clients at $13.00 a pop. Will pay for attorneys and accountants.

As to Priority Mail/ tracking/proof, why do we tolerate such a byzantine battle-prone system? Think of the man-hours Yves and countless others spend on running down this hors*#t. If she and others (doc offices/ care providers?) billed Cigna and others at a reasonable but market-based hourly rate for the collective man-hours spent on claims, Cigna et al would be out of business.

Its a level of complexity that is completely unnecessary. Our complacency, tolerance, and acceptance is pretty astounding. Must be the very real primacy of the threat and fear that personal health prompts. Immoral to lever off of this. Care versus insurance. Insuring a mortal being. Ridiculous premis only Wall Street could concoct. And we buy it because markets, capitalism, rugged individualism, American Exceptionalism.

Doc friends and family consistently state 35-40% of their costs, staff deals with billing, coding, reimbursement. There is huge savings to be gained in the process if we would go to a single payor system.

But you all know that- preaching to the choir.

I am still trying to figure out how to tie personal health choices, like diet and exercise, moderate alcohol use, etc.. and some incentivized skin-in-the game, some 'pain' disincentivises folks from over-using single payor and insisting on the highest dollar cost latest most expensive treatments -- how can this be institutionalized?

But , no need to reinvent the wheel- countless other nation-states have figured it out. For a nation of business-persons, we appear to be, as my old dad used to say, dumberthanwhaleshit

hunkerdown , January 9, 2019 at 12:04 pm

If they're overusing the system, what's the underlying reason? Probably loneliness or neurosis, either treatable on an outpatient basis as a mental/community health matter. If they demand heroic treatments or frivolous diagnostics , what's the underlying reason? Probably the consumer model of medicine and direct-to-patient marketing of interventions, also easily treatable (through restriction of advertising) and known to work well in other nation-states. If they eat crap, what's the underlying reason? The standard American diet is a consequence of national policy to grow grain instead of vegetables, which can be changed slowly and with effort as a public health hazard. If they don't exercise, what's the underlying reason? Built environments and lifestyles that are hostile to pedestrian traffic, which is not necessarily such an easy problem to solve due to the private interests and investments in the status quo, but whose opposing public interests would grow much stronger under a single-payer system.

Yet, all of these solutions, however difficult and world-changing they might be, are more effective over the long term and less resentment-inducing than having citizens pay to be individually scourged as a service in the name of individual incentive.

Yves Smith Post author , January 9, 2019 at 3:10 pm

The overwhelming majority of people do not elect to overconsume medical care.

People who don't exercise often don't have the time or money to do so (gym membership). Do not say "Anyone can run." Running on pavement is knee replacement futures. And there are people like me who could never jog even when young.

The ones that do fall into a few categories:

1. Ones with "lifestyle" diseases, like diabetes due to overweight/poor diet and smoking-related diseases. Problem is that these are typically the result of stress. Very hard to get off cigarettes and harder if you are subject to stress/use nicotine as a performance drug. Obesity significantly due to American portion sizes. too many refined carbs, and again, stress. And once people get fat, it is very hard for them to take and keep the weight off. I have managed to do so by virtue of seriously undereating for 40 years (<1200 calories/day, and that includes when I was exercising vigorously pretty much daily). Most people can't do that for social reasons. It is hard to be a meager eater when you are eating with other people.

2. People who are already have a problem and have been marketed to to demand tests and treatments. The classic version of this is doctors prescribing antibiotics to people with flus. The patients demand a treatment and the MD does not want to get in an argument. More extreme is patients not wanting to hear that there aren't any good options for what they have and shopping for an MD who will intervene anyhow. Another is all those new pricier drugs marketed on TV "Ask your doctor about..."

beth , January 9, 2019 at 8:15 pm

The best information about obesity is still the UCSF researcher Robert Lustig. He now has his own website but it not organized well to my taste and fails to keep the best long lectures there. Actually the best information in the shortest time is his first lecture that has been seen millions of times by geeks like me is "Sugar: The Bitter Truth" a one hour and 29 minute lecture he did in 2009. Youtube cuts it up and wants me to pay for it. But each time I have seen it has been on UCTV or UCSF. For those of us who want to understand the science this one is a must. There is good videos after that, but this is the foundational scientific information.

I can't give you a link because Google and the sugar industry makes it maddingly hard to find and moves it around.

flora , January 9, 2019 at 9:46 pm

It's a very good presentation. Thanks for the reminder. From UCTV:

https://www.uctv.tv/shows/Sugar-The-Bitter-Truth-16717

bob , January 9, 2019 at 3:21 pm

"I am still trying to figure out how to tie personal health choices some incentivized skin-in-the game "

You're trying to noeliberalize it. "How do we build in the need for 18 layers of very well paid bureaucrats who deal out spite, and lack of care, as part of their job descriptions?"

I can't imagine any more 'skin in the game' than all of the skin, and literally all of the person.

Do you ghouls even read what you write?

k. , January 9, 2019 at 9:59 am

As someone who managed a medical billing office in the 80s and 90s I can assure you that insurance companies losing claims is nothing new. That's why the advent of electronic billing to Medicare and Medicaid and BCBS and others was so wonderful. Finally, Medicare stopped "losing" all those claims we offices had to refile all of the time.

Sometimes it helped me to envision the office I was sending the paper claim to, imagining a constant turnover of new employees who didn't know what they were doing, or throwing away a stack of bills at the end of the day because they hadn't met their quota.

It's like borrowing "your" money longer, not paying what's owed in a contract.

EoH , January 9, 2019 at 10:38 am

Thanks for sharing.

This seems reminiscent of bank ATM fee scams. A dollar here, $2.50 there – systemwide – and soon you're talking about real money. It also matters whose budget the costs or income are shifted to, which is often a highly-competitive internal game. Same with the now ubiquitous and easily incurred penalty charges, which banks use to generate the outlandish returns they now consider their due.

Coincidentally, I was recently helping a friend with her latest medical bill. Always good sport if it's not your bill. It was "only" for about a thousand dollars. Her insurer paid the amount, minus her deductible.

The hospital system sent her a follow-up bill for the same service. It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not.

Here's the hospital's argument: It had billed the insurer and the patient only a thousand dollars. But the insurer considered bills for up to two thousand dollars for that service. Having, in effect, underbilled the insurer, the hospital added the difference between its first bill and the maximum amount the insurer would consider.

But the hospital did not bill the insurer for the higher amount, only the patient. That routine also happily avoided any reasonable and customary cap the insurer and hospital had agreed to.

The hospital does this routine systemically. Its "customer service" operators have a canned response for outraged patients: You'll pay it in the end and we'll dock your credit score in the bargain. Film at eleven.

Steven Hoel , January 9, 2019 at 10:39 am

I have found this letter (or to be used as script to be read over the phone) to be 100% effective so far. I suspect it gets kicked up to a supervisor who wants to get rid of the crazy customer:

"To: "Big Corporation"
Regarding Inv #

Hello,

You have issued your fourth notice. Please note that this is now my third notice to you of whom to bill. If I must spend more time on this issue, I will be billing out at $200 per hour in ½ hour increments. Sending a further notice without contacting "XYZ Healthshare" for payment will indicate acceptance of my terms.

This blood work was for my annual Physical. I am covered under "XYZ Healthshare" and they cover one physical per year.

Please submit above referenced invoice for payment to:

"XYZ Healthshare"
Payor ID:
P.O. Box 1234
Anytown USA 12345

Insured: John Doe
Policy # 123456789

It is not acceptable to simply send me another payment notice when you are not billing as I instructed. I will send my billable hours in return and submit a copy to my attorney.

Best Regards,

John Doe"

NotTimothyGeithner , January 9, 2019 at 10:44 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Perfect.

jrs , January 9, 2019 at 12:56 pm

Of course Trump's misdeeds are becoming abuses much closer to home, having one's government closed becomes real impractical even on the day to day level.

Spring Texan , January 9, 2019 at 11:08 am

Wow, this makes me very happy I work for a self-insured employer which unfailingly pays bills in good faith. Awful.

California Bob , January 9, 2019 at 12:10 pm

I was with United Healthcare in the private sector for years, with good coverage and no serious issues (PPOs only). When I went on Medicare, I stayed with AARP-endorsed UHC; I figure the last thing UHC would want is a bunch of angry retirees with time on their hands. So far, so good.

Jimmie Q , January 9, 2019 at 5:40 pm

I don't know about that. I've not been able to login to the AARP/UHC website for 2 months.
They admit that there is a problem. After 2 months I'd say they are correct.
You'd think they would go back to the last working version of their log-in software.
What kind of testing was performed before inflicting this crap on their users. None, by the looks of it.
It's pretty obvious when you can't login. How stupid are these people ?

Oregoncharles , January 9, 2019 at 12:17 pm

Not medical, but a similar penny-ante scam that we encountered from a car rental, which I will name: it was Dollar/thrifty – they're the same company. Ironically, we were happy with their service, given the price, UNTIL we turned the car in at the Indianapolis airport. The agent claimed the system was down, so couldn't give me a receipt; foolishly, and feeling time-pressured, I walked away without one (don't do that).

The company first claimed the car had not been turned in, then discovered that it had been re-rented the next day, so charged us for an extra day. I refused to pay it, since an agent had agreed that our boarding passes from the airline proved when we'd turned it in. In fact I got the credit card company to reverse the extra amount (their service was exemplary). Attempts to clear it up on the phone led to hangups at their end, and ultimately they sent the $50 difference to collection. When I got a call, I started yelling about it being a fraudulent charge and making legal threats; never heard from them again – not worth it for such a small amount. I felt that principle was involved.

And now the oddity: Dollar/Thrifty belongs to Hertz, but we've had no trouble renting from Hertz. Go figure.

JerryDenim , January 9, 2019 at 1:21 pm

One scam I've seen Hertz attempt on me twice, was claiming a car wasn't returned completely full, like 1/16th shy of full, then they proceed to charge you for a full tank of gas (15, 20 gallons or whatever that means based on the vehicle) at some outrageous price like $9.00 a gallon. It's a scam that is always going to add up to over a hundred dollars. It's a quick, vicious one-time burn (sharp practice as Yves would say) they try to pull on customers they figure may never rent from them again anyway. Algos I'm sure. Always document, document, document with rental cars. Cell phone cameras are great in this regard. Photos of the odometer with gas gauge displayed work great for refuting such charges.

beth , January 9, 2019 at 8:32 pm

I was definitely scammed by Dollar/Thrifty. I have switched to using Enterprise but they sometimes don't have an airport location. So far so good. I usually take only one trip a year.

Oregoncharles , January 9, 2019 at 12:21 pm

Afterthought: Insurance is a service business, which would normally depend on providing reasonably good service – granted, in this case Yves is locked into an old contract, so they might be trying to get rid of her.

I wonder if this sort of behavior means they see the political handwriting on the wall, figure the business can't last much longer, and are trying to extract the last dime, because it IS the last?

EoH , January 9, 2019 at 3:13 pm

Standard business model. Nothing special.

I question whether insurance is any longer a service, at least for the customer. Health insurance used to be a business that offered a reasonable service, service tracking and payment processing for employers, who purchased the service for their employees as a form of deferred compensation, in exchange for a reasonable fee.

The model seems to have changed to one of open and notorious self-dealing. The intermediary has become a principal, and no fee and no level of profit is too great. The intermediary makes decisions that look to the lay person like practicing medicine – not seemingly in the interest of savings its employer customers money, but it making it for themselves. The model is a major reason for the extraordinary cost of medical care in the US.

Synoia , January 9, 2019 at 12:26 pm

Small claims court?

ambrit , January 9, 2019 at 12:57 pm

That would be a tax on her time, she has to physically show up in court for the 'trial', and money, as in, filing fees. A small claims judgement does not guarantee payment. That could take a second suit. (I had to go for a second filing to get my judgement paid.)
This is a systemic problem. The remedy in that elusive "perfect world" is to change the system.

AdamK , January 9, 2019 at 12:55 pm

"Corporate America has been institutionalizing penny-ante scams "

Don't get me started. 24 hour fitness sold membership for super sport facilities at a higher price promoting the deal that gives free towels to members while at the gym. 3 years after, towels are gone. Price was raised several times, and there is no difference between regular facility and super sport. No one complained. They simply got the news and adjusted. Saying something is not considered appropriate, so we continue to pay more and more and getting less and less.

ambrit , January 9, 2019 at 1:05 pm

Same dynamic used for Internet services, telecom services and cable services. Life is legally an "ethics free zone" today.
Reminds me of one of the more vulgar posters I once saw. A mid range shot of a woman's "private parts" with a 'tattoo' above the mons pubis saying; "Abandon all hope, ye who enter or exit here."

WheresOurTeddy , January 9, 2019 at 2:32 pm

seems germane:

"The political crisis we are facing is simple. American commerce, law, finance, and politics is organized around cheating people." – Matt Stoller

https://twitter.com/matthewstoller/status/893848256769171458

JerryDenim , January 9, 2019 at 1:10 pm

This story is strangely similar to the battles I used to wage years ago with Sallie Mae to pay down my student loan principal ahead of schedule. I would send checks that would never be cashed. If they ever were the amount would always be applied to interest and never principal. Tons of emails, phone calls and letters stretching out over months all about one check or another.

"Oh you sent the check to that address? No that's all wrong, try this one." "Oh, no, you have to write a letter stating you want the amount to be applied to principal. Oh, you did already? Oh, well send one to this department at this address instead and your next one should be be applied to principal."

Absent an aggressive regulator corporations can play infuriating games like this for years until the consumer gives up or lawyers up. Lawyering up is no guarantee of victory and doesn't make financial sense for small penny-ante grievances. Most people stuck dealing with hassles like these don't have the money to lawyer up anyway and corporations know it. I remember back in 1995 when my phone service was changed without my permission and I received an outrageous bill. I placed one phone call to the FCC that lasted a few minutes and I received a $250 credit and my phone service was free for the next year. I miss those days.

"The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home."

Absolutely. It's really tough for working class Americans to shed a tear for Central American border jumpers having a rough go of things with ICE when their own government refuses to protect them from thousands of small capitalist depredations that they are subjected to on a daily basis.

tongorad , January 9, 2019 at 1:11 pm

Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me
I received an errant charge when I chose to cancel my account with a phone-carrier giant. Lots of time on the phone speaking to different people, demanding to be sent an invoice/bill.
In the end, I just paid. I was losing sleep over it.
I have a feeling that these kinds of extractions are commonplace.
What a world

beth , January 9, 2019 at 8:41 pm

If we are discussing scams, I had an earthlink account for about a year when I noticed that rather than billing me monthly, they were billing me every 20 days and when I noticed it, they said they would refund my money at my request.

And what do you think happened?

M Morrissey , January 9, 2019 at 1:20 pm

File a complaint with your state insurance department. Most departments have dedicated staff who will follow up on such issues. If you one of many victims, it can lead to a "Targeted Market Conduct Examination" of the company.

Once that happens, the insurer will readily settle claims such as yours because besides fines, the impact of an examination damages their reputation. Also, if there is a pattern of misconduct, the complaint information is shared between the 50 states, who may also initiate targeted examinations. Don't get mad–get even.

monday1929 , January 9, 2019 at 6:06 pm

You are kidding, right?
And ."damage their reputation"- thank you, I needed a laugh.

JBird4049 , January 9, 2019 at 1:37 pm

The more people are in need of medical care the less likely they are to have the time, energy, or even money to maintain their records, read all their letters and emails, and write and call enough times to finally get their money. The sicker are the less likely you will get paid. Truly vulture capitalism.

Dan , January 9, 2019 at 1:57 pm

I tend to agree that these 'billing mistakes' are a conscious strategy on the part of insurers. For several years Kaiser (Northern California) would attempt to bill me $15 every time for routine physical visits (which my physician had requested!). Routine physicals, of course, are meant to be free under the ACA. Every time the receptionist would request payment in advance, I would decline an tell them that the appointment should be free. They then would proceed to bill me by mail, and I had to spend time calling them to resolve the issue. Unlike Yves' experience with Cigna, Kaiser customer service was always friendly and promptly resolved the 'error'.

Since we changed from a Covered California plan to a small business plan this practice appears to have stopped, at least for me. Nonetheless, this annual ritual was a ridiculous tax on my time, and I wonder how many people who were less informed/hostile to their insurer than I am have just paid these false and illegal fees up front. The consistency of this practice over a period of years makes it hard for me to believe that there is really error involved, as opposed to a subtle fraud by the insurer.

monday1929 , January 9, 2019 at 6:13 pm

It is never an "error", and it is always in their favor (proof it is not an error).
They target the sickest, least likely to fight back. There is an MBA somewhere who wrote an algorithm designed to screw the old and sick. My nightmare with United "healthcare" (why are they allowed to call themselves or imply they are healthcare providers?) was on behalf of someone else who never could have fought these scammers.

tiebie66 , January 9, 2019 at 3:31 pm

So, they legislate to permit disruption against you and not against them, but year after year – figuratively speaking – you send the same people back there. The system is beyond reform, is that not clear by now? Vote for anyone –except– a Democrat or Republican. It would create upheaval at first, like spring cleaning, but it is as necessary. If you are too timid to make changes, you will only get weaker and weaker until you are too weak to resist. Don your yellow jackets!

But on a different level – where does this originate? My sense is that it is a failure of education. The nation can neither read, nor write, nor think. This makes for easy victims. Do teachers really deserve better pay? Is teaching not a 'calling' rather than a career? Should teachers not do better? But perhaps the failure of education is also, in part, institutionalized?

Big Tap , January 9, 2019 at 4:55 pm

Speaking of insurance scams some involve a PPO type policy. More and more often I'm told at the time of service of a doctors visit to pay up front. With a PPO policy you usually don't know exactly what you owe till after the insurance company tells you what your co-pay is and then you're billed. When you pay up front bring overcharged intentially is the scam. Getting a refund of your own money can time consuming.

Pft , January 9, 2019 at 6:49 pm

Not only health insurance. Good luck if your house burns down and you want them to honor the contract in a timely fashion. They hold off until you accept less hoping you hate living in 2nd rate accomodations enough to cave. My sisters contract called for full replacement of all contents regardless of age. She paid a hefty premium for that. They held out for months offering less saying some of the contents were older and not worth the replacement cost which is what she wanted to avoid by paying the extra premium for the upgrade. Came to an agreement somewhere between but took 15 months before she could move back in.

EoH , January 9, 2019 at 7:37 pm

There is the basic problem that with almost every medical service, the customer does not know the price until the bill(s) show up in the mail. (Nor have they any training or experience that would enable them to choose alternative treatments or vendors.) Only later still does an insured customer find out what portion of that bill is her responsibility. And that's without errors and intentional mis-billing, which are common.

The usual conservative refrain that patients need more skin in the game studiously ignores that patients always have all their skin in the game, even though no one tells them the game or the rules until it's too late. It is an environment that could only make predatory behavior flourish.

Katherine , January 9, 2019 at 9:57 pm

This is one of the most unsettling posts I have read on NC since becoming hooked about 6 months ago.

cat sick , January 10, 2019 at 2:44 am

Live a healthy lifestyle and self insure

I am sure not dealing with insurance companies is a sure way to lower stress levels and therefore require much less healthcare.

As a fairly healthy 50 year old I find that even though I have access to a good free first world healthcare system (Singapore ), never using it and paying doctors direct for all my needs is the way to go and probably costs me 10% of what a US citizen might pay for an insurance policy.

When I am in the US and so many people you meet have "meds" that they take on a daily basis it leads me to believe that not only are the insurance companies in on the scam but also the doctors and drug companies plying people with drugs that in most cases probably make them worse off

The first $20 of care I would reccomend is to buy one copy each of "how not to die" and "the case against sugar" read these and then do all you can to avoid both insurance companies and doctors .

[Jan 09, 2019] $3.5 Trillion A Year- Is America's Health Care System The World's Largest Money-Making Scam- -

Jan 09, 2019 | www.zerohedge.com

Authored by Michael Snyder via The Economic Collapse blog,

If the U.S. health care system was a country, it would have the fifth largest GDP on the entire planet. At this point only the United States, China, Japan and Germany have a GDP that is larger than the 3.5 trillion dollar U.S. health care market. If that sounds obscene to you, that is because it is obscene. We should want people to be attracted to the health care industry because they truly want to help people that are suffering, but instead the primary reason why people are drawn to the health care industry these days is because of the giant mountains of money that are being made. Like so many other things in our society, the health care industry is all about the pursuit of the almighty dollar, and that is just wrong.

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In order to keep this giant money machine rolling, the health care industry has to do an enormous amount of marketing. If you can believe it, a study that was just published found that at least 30 billion dollars a year is spent on such marketing.

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products -- from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing nearly doubled from 1997 to 2016, soaring to at least $30 billion a year , according to a study published Tuesday in JAMA.

This marketing takes many different forms, but perhaps the most obnoxious are the television ads that are endlessly hawking various pharmaceutical drugs. If you watch much television, you certainly can't miss them. They always show vibrant, smiling, healthy people participating in various outdoor activities on bright, sunny days, and the inference is that if you want to be like those people you should take their drugs. And the phrase "ask your doctor" is usually near the end of every ad

The biggest increase in medical marketing over the past 20 years was in "direct-to-consumer" advertising, including the TV commercials that exhort viewers to "ask your doctor" about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016 , according to the study.

As a result of all those ads, millions of Americans rush out to their doctors to ask about drugs that they do not need for diseases that they do not have.

And on January 1st, dozens of pharmaceutical manufacturers hit Americans with another annual round of massive price increases.

But everyone will just keep taking those drugs, because that is what the doctors are telling them to do. But what most people never find out is that the pharmaceutical industry goes to great lengths to get those doctors to do what they want. According to NBC News , the big drug companies are constantly "showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences".

It is a legal form of bribery, and it works.

When you go to most doctors, they will only have two solutions to whatever problem you have – drugs or surgery.

And since nobody really likes to get cut open, and since drugs are usually the far less expensive choice, they are usually the preferred option.

Of course if doctors get off the path and start trying to get cute by proposing alternative solutions, they can get in big trouble really fast

Today's medical doctors are not allowed to give nutritional advice, or the American Medical Association will come shut them down , and even if they were, they don't know the right things to say, because they weren't educated that way in medical college. So instead, M.D.s just sling experimental, addictive drugs at symptoms of deeper rooted sicknesses, along with immune-system-destroying antibiotics and carcinogenic vaccines.

That's why any medicine that wrecks your health is easy to come by, just like junk food in vending machines. The money isn't made off the "vending" products, the money is made off the sick fools who are repeat offenders and keep going back to the well for more poison – it's called chronic sick care or symptom management. Fact: Prescription drugs are the fourth leading cause of death in America, even when "taken as directed."

Switching gears, let's talk about hospitals for a moment.

When you go to the hospital, it is often during a great time of need. If you are gravely ill or if an accident has happened and you think you might die, you aren't thinking about how much your medical care is going to cost. At that moment you just want help, and that is a perfect opportunity for predators to take advantage of you.

Trending Articles "A Soft Coup Against Donald Trump Is Underway" Declares

Turkey is going on the attack against John Bolton following his weekend antics in the Middle East, which most recently

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Just consider the example of 24-year-old Nina Dang. She broke her arm while riding her bicycle in San Francisco, and so she went to the emergency room.

The hospital that Facebook CEO Mark Zuckerberg donated so much money to definitely fixed her arm, but later they broke her bank account when they hit her with a $24,000 bill

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50 . Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay , which the hospital threatened to send to collections in mid-December.

Most Americans assume that if they have "good health insurance" that they are covered if something major happens.

But as Dang found out, you can still be hit with crippling hospital bills even if you have insurance.

Today, medical debt is the number one reason why Americans declare bankruptcy. Because of the way our system is set up, most families are just one major illness away from financial ruin.

And this kind of thing is not just happening in California. The median charge for a visit to the emergency room nationally is well over a thousand dollars , and you can be billed up to 30 dollars for a single pill of aspirin during a hospital stay.

Our health care system is deeply broken, and it has been designed to squeeze as much money out of all of us as it possibly can.

Unfortunately, we are stuck with this system for now. The health care industry is certainly not going to reform itself, and the gridlock in Washington is going to make a political solution impossible for the foreseeable future.


the_river_fish , 3 minutes ago link

Healthcare has displaced Retail as the largest employer in the United States

https://thistimeitisdifferent.com/healthcare-us-january-2019

Consuelo , 9 minutes ago link

The ghost of Ted Kennedy that keeps on giving...

He played an outsized role in the trashing of the doctor/patient relationship.

css1971 , 10 minutes ago link

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered "in-network." Zuckerberg San Francisco General has not done that bargaining with private plans, making them "out-of-network." That leaves many insured patients footing big bills.

HMOs.

Constrain supply. Increase the price.

https://en.wikipedia.org/wiki/Health_Maintenance_Organization_Act_of_1973

That was the purpose of the 1973 HMO act. It was at this point, that US medical costs began to escalate far beyond the rest of the world.

https://pusz4frog.files.wordpress.com/2012/04/healthcare-costs-oecdchart_3.gif

LawsofPhysics , 10 minutes ago link

Considering the demographics of the country and the fact that fraud is the status quo now, this should not surprise anyone.

LawsofPhysics , 21 minutes ago link

That's a tough question considering we don't really know how much is flowing to the military industrial complex. My guess healthcare spending is in second place.

[Jan 08, 2019] Risk On Again - Distractions from the Real Problems and Issues

Jan 08, 2019 | jessescrossroadscafe.blogspot.com

Stocks and Precious Metals Charts - Risk On Again - Distractions from the Real Problems and Issues

"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December..."

Sarah Kliff, A $20,243 bike crash: Zuckerberg hospital's aggressive tactics leave patients with big bills

"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."

Elizabeth Warren

Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be free to do just about whatever they wish in billing consumers.

Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common sense, with Big Pharma running a close second. But the Banks are not all that far behind.

I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being swept along because they have little practical recourse or power. To speak up is to be punished, and severely.

A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will be done at the Medicare rate and not at some ficitonal billing statement.

I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never informed beforehand.

The real solution is of course universal healthcare, which has been implemented for years by every major developed nation but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.

Stocks managed to extend their rally today despite some setbacks.

We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare, finance, insurance, or pharmaceuticals.

Have a pleasant evening.

[Nov 26, 2018] >Revealed: faulty medical implants harm patients around world by Hilary Osborne , Hannah Devlin and Caelainn Barr

Notable quotes:
"... In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world. ..."
"... Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated. ..."
Nov 25, 2018 | www.theguardian.com
The Implant Files investigation reveals damage caused by poor regulation and lax testing rules

Why we're examining the implants industry

Patients around the world are suffering pain and many have died as a result of faulty medical devices that have been allowed on to the market by a system dogged by poor regulation, lax rules on testing and a lack of transparency, an investigation has found.

Pacemakers, artificial hips, contraceptives and breast implants are among the devices that have caused injuries and resulted in patients having to undergo follow-up operations or in some cases losing their lives.

In some cases, the implants had not been tested in patients before being allowed on to the market.

In the UK alone, regulators received 62,000 "adverse incident" reports linked to medical devices between 2015 and 2018. A third of the incidents had serious repercussions for the patient, and 1,004 resulted in death.

In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world.

These included 1.7m reports of injuries and almost 83,000 deaths. Nearly 500,000 mentioned an explant – surgery to remove a device.

The figures come from research by 252 journalists from 59 media organisations in 36 countries, which has uncovered a litany of problems in the global $400bn (£310bn) industry.

Examples of failure in the market include:

Replacement hips and vaginal mesh products sold to hospitals without any clinical trials. Patients relying on faulty pacemakers when manufacturers were aware of problems. Complications with hernia mesh that ruled one of Britain's top athletes out of competing for years. Regulators approving spinal disc replacements that later disintegrated and migrated in patients. Surgeons admitting they were unable to tell patients about the risks posed by implants because of a lack of central registers. Patients in Australia being given devices that the regulator has approved on the basis they have been approved in Europe.

The findings raise concerns about the level of scrutiny devices undergo before and after they go on the market, and whether regulators detect and act upon findings quickly enough.

Information about problems with devices is, in many countries, kept under wraps, making it difficult for patients to research procedures that have been recommended to them.

Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated.

Prof Derek Alderson, the president of the Royal College of Surgeons, said there had been enough incidents involving flawed devices to "underline the need for drastic regulatory changes", including the introduction of mandatory national registries for all implantable devices.

"In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence," he said. "This is a risk to patient safety and public confidence."

The Guardian and organisations including the BBC , Le Monde and Süddeutsche Zeitung, coordinated by the International Consortium of Investigative Journalists (ICIJ), have trawled through thousands of documents, many obtained through freedom of information (FoI) requests, to unearth some of the biggest problems.

Alongside interviews with patients and doctors, these have revealed flaws in the way the industry is regulated that are unlikely to be fixed by rules due to come into force in Europe.

Among the concerns raised by the Implant Files project are that manufacturers are in charge of testing their own products after faults have developed – and are allowed to shop around for approval to market their products, without declaring any refusals.

The Guardian has also heard about doctors who have close industry ties or seem eager to be early adopters of the latest devices to enhance their professional standing.

Plans for tougher EU rules have been watered down after industry lobbying, according to a huge trove of documents uncovered by the project.

[Oct 27, 2018] Surgery on a Sunny Afternoon Got Me Thinking About Healthcare

Notable quotes:
"... Millions young and old, caught up in the struggle for Healthcare and now there's a consensus. ..."
caucus99percent
span y divineorder on Sat, 10/27/2018 - 1:52pm Millions young and old, caught up in the struggle for Healthcare and now there's a consensus.

Yesterday we caught the bus downtown to the Dragon Room in the Santa Fe Plaza area for Happy Hour to meetup with friends we hadn't seen in a year. Heh. As happens with we seniors, part of the time was spent catching on health issues.

Our friend is facing knee replacement surgery with complications. Carpenter property manager by day, musician by night, he was worried about how things would turn out. But at least he had coverage through his wife's employment. Millions still don't have healthcare, and many who do, face denial of coverage and worse.

It clearly is a huge issue for some in the upcoming midterms.

Senior or no, perhaps you, too are worried about how things will turn out?.

Medicare Advantage vs. Medicare for All https://t.co/EFG1G4QKCS

-- Alice Marshall (@PrestoVivace) May 31, 2018

For those who followed the healthcare debacle during Empty Suit era it has been gratifying to see the coverage and movement toward single payer.

But there are still serious obstacles.

Dr. @awgaffney details the barriers to #SinglePayer reform: "Obstacle number one is the corporate opposition, obstacle number two is the potential that #MedicareForAll could be co-opted or sort of mutated into a lesser thing." https://t.co/E4xTSBPx2E via @businessinsider

-- PNHP (@PNHP) October 26, 2018

Here's another link for those who want to educate themselves on MA vs IMFA.
http://healthoverprofit.org/2018/03/27/medicare-advantage-vs-medicare-fo...

Over the last few decades, insurers participating in Medicare Advantage have schmoozed Congress into compensating them with more money per person than is allocated to traditional Medicare. Don McCanne of Physicians for a National Health Program writes:

"Each year the administration, whether Democratic or Republican, uses quirky arcane rules to ensure an adequate revenue buffer so that private insurers can compete favorably with the traditional Medicare program by offering lower premiums and cost sharing and expanded benefits Once a critical mass has enrolled in private plans, Congress will gradually reduce the relative value of the voucher-equivalent, reducing the government component of the funding of Medicare by shifting more costs to the Medicare beneficiaries."

We see this happening right now, with top leaders of Republican Party expressing a strong interest in cutting Medicare. In response, physician advocates argue that the private Medicare Advantage HMOs should be isolated as a source of wasteful government spending, and that benefits offered by these plans should be expanded into traditional Medicare. Physicians for a National Health Program (PNHP), the doctor-led think tank for single payer policymaking, has been putting forward a strong case against Medicare Advantage for some years.

PNHP points to a number of studies that show the Medicare Advantage HMOs cherry pick healthy patients and lemon drop expensive, unhealthy ones. This is done through narrow coverage networks and poor access to specialized care , driving patients with heavy medical burdens into traditional Medicare – where they can choose their own providers. A 2015 Brown University study showed that of Medicare Advantage patients who had long-term stays in nursing homes, 17% switched to traditional Medicare the next year. The report's lead author, Momotazur Rahman, told NPR news that there are incentives, including "steep cost-sharing as patients need more expensive care" and "limitations on expensive treatments",that because sick patients to drop out of Medicare Advantage plans. A 2017 Government Accountability Office (GAO) report found that of 126 Medicare Advantage plans, 35 plans saw disproportionally high numbers of sick enrollees dropping out into traditional Medicare.

In 2017, a Kaiser Family Foundation (KFF) study found one out of every three Americans enrolled in Medicare Advantage plans were given narrow physician networks. It concluded that plans offering broader networks tended to have much higher premiums than narrow-network plans. KFF also found that one out of every five plans do not include a regional academic medical center in their networks, and estimated that 40% of Medicare Advantage networks included top-quality cancer centers.

The Medicare Advantage insurers can also increase their profits by upcoding the severity of the diseases that their patients have. HMOs are paid per capita based on the number of patients they cover. The payments are also risk adjusted according to the severity of the illnesses of those covered: the more severely ill, the higher the compensation. So it is to the Medicare Advantage plans' advantage to upcode, to make patients seem sicker. Investigations by the Center for Public Integrityand the work of academics show that there is both direct and indirect evidence of massive upcoding in Medicare Advantage, costing the government and taxpayers tens of billions of dollars.

While Medicare Advantage is not an efficient or an equitable means of offering care to senior and disabled Americans, it's important to look into some of the benefits that satisfied patients (who tend to be healthy) are grateful for. All of these benefits would be offered (and enhanced) through a national health insurance system like National Improved Medicare for All (NIMA).

Sorry for leaving out the extensive hot links in the above quote.

So as before its a crapshoot that the Dems and their Repub buds won't screw this up for us.

My wife C99er jakkalbessie and I rode our pedal assist bikes down the Arroyo de Chamisa Urbano to the grocery store this morning, and it is one beautiful fall day here in
The City Different. Leaves are changing, there's a little snow up on the mountains east and west. Such a glorious day to be alive, and able to pedal around still!

I got to get my butt in gear and get ready for MOHS surgery. Spending too much time out in the sun, I guess.

Running through my mind are thoughts like " How much will I have to end up paying? Will my Medicare Advantage Employer group coverage try to deny it?"

What if I were like millions, with no coverage at all? My brother has a much larger problem on his face and no insurance what so fcking ever.

It's all but guaranteed that Trumpco will finally strangle ACA to death and soon. And then there's the worry about how corpadems can fck everything up.

What are people going to do? All the best to you and yours, good health to all.

Of course its not just we mouldy odies that care about this sheet.

AP-NORC/MTV Poll: Young people back single-payer health care https://t.co/pnBGhCq0Pq

-- Health Care For All (@HCASFV) October 26, 2018

Young Americans called health care a very important issue in deciding how to vote. Sixty-two percent of those who will be old enough to vote in the midterms rated it as such. That's the most who said the same of any issue in the poll, including... https://t.co/K2oMRAXPRz

-- Big Easy Magazine (@bigeasy_mag) October 27, 2018


More power to us all.

Wish me luck! Hoping to be in the 94% success rate for this surgery. Divineorder.

[Oct 25, 2018] Is Medicare for All the Answer to Sky-High Administrative Costs? by Lambert Strether

Oct 25, 2018 | www.nakedcapitalism.com

"Is Medicare for All the Answer to Sky-High Administrative Costs?" [New York Times].

The answer will surprise you! "Medicare's direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending.

Yet the program's total administrative costs -- including those of the private plans -- have been rising. 'This reflects a shift toward more enrollment in private plans," Mr. [Kip] Sullivan said.

"The growth of those plans has raised, not lowered, overall Medicare administrative costs.'" • It is very gratifying to see a single payer stalwart like Kip Sullivan quoted as the authority he indeed is.

And, contrary to the headline, it does look like Medicare has a bad neoliberal infestation that needs to be dealth with. "Free at the point of delivery" is a good starting point, because that strikes a deathblow at the complex eligibility determination process so beloved by markets-first liberals.

[Mar 21, 2018] Big pharma racket: Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry

Notable quotes:
"... instruction manual ..."
"... Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription. ..."
"... " experts say " ..."
"... medicine is less expensive if you pay the cash price and we don't run it through your health plan ..."
Mar 21, 2018 | www.nakedcapitalism.com

Enquiring Mind , March 20, 2018 at 9:17 am

Shame is a 20th century concept ill-suited to this modern post-tobacco settlement world. Where some saw a consumer victory after decades of warnings on packs by getting big tobacco to acknowledge risks, others saw methodology victory for the neo-liberal machine, and an instruction manual .

Like the Big C, cancer, that machine keeps rolling along. Now it is mainstream, to be emulated instead of castigated. At least that is what appears to have happened among those shame-free star pupils of Big Pharma and their fellow travelers in FIRE, aided and abetted on the Big Screen where deviancy got defined down so far it got erased. Political and economic trends ebb and flow, with some elements of populism appearing on the horizon. Greater awareness of the plight of one's fellow humans may help focus the mind.

RabidGandhi , March 20, 2018 at 6:16 am

Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription.

Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry. Bottom line, medical professionals and patients have to spend their time and effort (increasingly dwindling, because markets) to try to avoid being charged a month's pay for a tube of ointment. Because, bottom line, changing the system is not an option, so keep banging your head against that wall!

notabanker , March 20, 2018 at 6:36 am

Yeah, try getting a straight answer on what this stuff will cost BEFORE you take possession, er , are treated. "$200" has turned into $1000 bills from a third party device company that magically turns to $0 after 3 months of emails and phone calls. I've walked out of hospitals after getting full disclosure of costs minutes before a procedure that was scheduled weeks in advance.

The neolib corruption numbness has to seep through the cartilage into the bones to call these practices anything but criminal.

oh , March 20, 2018 at 2:30 pm

There is really no excuse for the crooks in the medical (health care? nah!) industrial complex not to provide costs of any procedure or service ahead of time. I admire you for walking out minutes before the procedure and more people should do the same. I would do the same and have.

Amfortas the Hippie , March 20, 2018 at 4:15 pm

If there's no "Price Discovery", is it really a "Marketplace"?

towards the end of my six and a half year slog through the disability process(sic), I learned about Cuba. I got a price for a new hip pretty easily from them (around 10 grand, including a "bungalo on the beach with a private nurse for recovery")

so I called the nearest hospital, and asked what a new hip would cost me, cash money, walking in the door.

The person obviously didn't understand the question, and after some time of me waving my arms and trying to word the question in a form she would understand she said" oh insurance takes care of that and it depends on many factors"

"such as?" sez I

Her:" like what kind of replacement they use which is up to the surgeon and many things"

This went on and on, and I finally got her not nailed down at around 300 grand.

Then I asked her what medicare would pay for the same thing and she hung up on me. It ain't a "Market", it's a Racket.

(and, about the toenail fungus my grandmother would tell her to just pee on it .)

Bukko Boomeranger , March 20, 2018 at 7:06 am

By the "logic" of the guest post, bottom line is it's that baby's fault for not being strong enough to defend itself against the big kid who took its candy. It's the woman's fault for dressing that way before she was raped.

The victims should be blamed because they didn't play defence well enough against the criminals who write the rules of the system. I presume your comment is to flesh out the BS justification from the article, Gandhi, not to endorse it. Excuses like the one capping the guest post, instead of rabid outrage, are part of what allows the crimes to continue. I can see why so many Merkins want to burn the (family blog)er down, even though they wind up voting for Trump as a means of expressing that feeling.

HistoricalPerspective , March 20, 2018 at 11:32 am

" experts say "

Seriously, who are these 'experts'!?!? Between the 'experts' , who blame the victims, kick cans down the road and pass the bucks to the lay-people (no one is an expert in everything, i.e. everyone is ignorant about something at some point in their lives) they're suppose to be advising whenever 'expertise' is required, and the 'journalists' who give them a venue to spew their apocryphal twaddle in an attempt to portray themselves as 'experts' when their true intentions are to gaslight, obfuscate and divide common sense and decency. Throw in the politicians, crony capitalists and all the other puppet masters and you have the perfect storm so many Americans, like myself, finds themselves drowning in. Once upon a time expertise inferred wisdom. Those days are history.

jackiebass , March 20, 2018 at 6:31 am

I don't know if it works but I've been told that petroleum jelly will cure toenail fungus. it seems salves or topical medicines are usually expensive. I use a salve that I apply to the rash from my. Eczema. I have used it for years and the price is constantly increasing. When I started using it the cost was $50 per tube. The last tube I got cost $480. I was prescribed an inhaler for Bronchitis. It cost almost $500 and didn't seem to do much to relieve the symptoms. Fortunately my insurance payed for the medicine. It still makes me mad when I think about what was charged for these prescriptions.

divadab , March 20, 2018 at 8:00 am

There are much cheaper alternatives to inhalers for asthma or bronchitis. Buy a "Nebulizer" (we just bought a portable one for $50), which is a vaporiser, and get your doctor to prescribe "nebules" of albuterol sulphate and/or sodium chromalyn to load into the nebulizer. We get a prescription refill of nebules for $3.49 v. over $50 for a ventolin inhaler . And there is no propellant in the nebulizer which there is on an inhaler.

The greed and parasitism of the pharmaceutical cartel is criminal.

Arthur J , March 20, 2018 at 10:13 am

My gp told me to use Vick's VapoRub for my toenail fungus. I asked the pharmacist and she said it has about a 10% success rate, same as the petroleum jelly from which Vick's is made. There was some branded treatment, $40 for a 2ml bottle that she said worked maybe 15% of the time. Only been a few weeks, but so far I haven't seen much of a change.

Eudora Welty , March 20, 2018 at 12:32 pm

Yes, I used Vick's Vaporub on a toe fungus and it worked. I was told it wouldn't work.

home for wayward trout , March 20, 2018 at 1:00 pm

The People's Pharmacy has a lot of information on toenail fungus and also has an article recommending treatment with mentholatum.

I now go to their website before filling any prescription I'm given by a doctor.

RalphR , March 20, 2018 at 8:22 pm

I did (after trying other topical but non-prescription products) and it didn't initially.

But then I used it in conjunction with a lotion with a lot of hyaluronic acid in it. Hyaluronic acid is widely used in cosmetic products to increase penetration of the active ingredients into the skin.

Worked great.

Just by sure to apply any treatment to the cuticle, particularly at the root of the nail. That is where the fungus lives.

donw , March 20, 2018 at 12:42 pm

It is a fungus, so being outside in the sun wearing flip flops might kill it.

Marie Parham , March 20, 2018 at 6:42 am

Last summer I had toenail fungus and researched how to treat it. Soaked my feet is diluted vinegar a few days and scrubbed the area. Then I used https://www.cvs.com/drug/miconazole . It worked. Next time I have an annual checkup I will talk to my nurse practitioner. Web MD was a big help. https://www.webmd.com/skin-problems-and-treatments/guide/fungal-nail-infections-topic-overview#1

So was Mayo clinic

https://www.mayoclinic.org/diseases-conditions/nail-fungus/diagnosis-treatment/drc-20353300

I am not recommending websites replace physicians, but apparently it is necessary to always second guess the physicians.
My treatment cost less than $10.

Normal , March 20, 2018 at 6:42 am

How about requiring every provider to give a firm quotation on every product and service? Every other industry has to live with this constraint.

XXYY , March 20, 2018 at 10:22 am

I'm amazed this simple idea never gets traction. Car mechanics, e.g., are required by law to provide a written estimate before work begins; if something is found that will change the estimate, they have to get your OK. Car repairs are usually much cheaper than medical bills and are often equally or more opaque to diagnose.

Having doctors and medical offices provide you with an estimate after diagnosis but before treatment does not seem like it would be terribly hard. They (uniquely) have visibility into your insurance arrangements, their reimbursement rates, their costs, overhead, profit rates, and so on. Software for this purpose would make pretty short work of boiling this down to the out-of-pocket for the patient. The patient could then either OK it, negotiate other options, or decide to shop around. If the provider later tries to charge more, the patient would have something on paper to justify refusing it.

There's no reason patients should be treated like a bottomless bank account by the medical industry.

sharonsj , March 20, 2018 at 12:58 pm

Many doctors have no clue what things cost. I received a single shot of cortisone for an arthritic shoulder and was charged $200. When I complained to the health care system, I was told that, had I been insured, the cost to me would be $100 less. When I complained to my doctor, he had no idea about any of this.

P.S. I knew the owner of an herb farm who had foot fungus. She visited a podiatrist and was prescribed some expensive salve which didn't work. The woman then went out on her farm, gathered some herbs according to an old remedy, made her own salve and was cured.

oh , March 20, 2018 at 3:02 pm

I was told to get the shot for shoulder pain (was a bad idea from this quacK). The "doctor" had no idea what it would cost!! At any rate it cost me over a $100 even with Kaiser coverage and it did NOT help. It hurt a lot for a few days (in more ways than one). What a fraud this industry is.

I dread the day I'd have to go to the hospital where I it was such an emergency that I'd be at the mercy of this robber baron system

JTMcPhee , March 20, 2018 at 10:25 am

Had any car or truck repair work done lately? Or speaking of things automotive, have any of us had experiences with the sales machinery of car and truck dealers, new or used? Speaking of transparency in pricing, firm quotes and all that? As just one example of how The Machine actually works? Catch-22: "They can do anything to us they want that we can't keep them from doing." http://www.slate.com/articles/life/the_spectator/2011/08/seeing_catch22_twice.html

FluffytheObeseCat , March 20, 2018 at 11:19 am

Big ones twice in the past four years on the RAV4. 2 different shops, in different states. They both gave me firm, up front price quotes. One was wrong on the low side, and the owner called me with the real price and an apology before doing the work. Just like the law requires.

This kind of fair dealing and respect for the customer never happens in medical practices. The doctors rarely soil their highly educated minds with matters of cost; everyone else in the office has little authority, and the chubby young women who sit up front in scrubs do as little as possible for the captives they call patients.

nycTerrierist , March 20, 2018 at 3:07 pm

"This kind of fair dealing and respect for the customer never happens in medical practices. "

This! And stress over billing affects health!
it is stressful and aggravating that doctors can't/won't address cost at the point of service. This destroys patient's trust in the physician as well.
Therapeutic relationship is wrecked as well as health and personal finances.

Paul P , March 20, 2018 at 7:19 pm

This NYS law applies to services, not drugs. It's a start:

Emergency Medical Services and Surprise Bills Law – New York State
https://www.health.ny.gov/regulations/ bill /ems_and_surprise_bills_law_faq.htm
If they do not participate in a patient's health care plan, they must upon request from a patient inform the patient of the estimated amount they will bill absent unforeseen medical circumstances that may arise. Under subdivisions (3) and (4), physicians in private practice also must provide information regarding any other ..

anonymous , March 20, 2018 at 6:57 am

"We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts ( and every breathing human ) said."

Eureka Springs , March 20, 2018 at 7:03 am

We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts said.

What kind of "expert" tries to rationalize cost of prescription on severity, rather than, say, cost of making the product?

16,500 for the course of an eleven month treatment with 6 percent chance of working. Seems like a medical RX vacation almost anywhere else in the world would be prudent.

Enquiring Mind , March 20, 2018 at 9:07 am

What kind of expert, you ask?

Today's fast-paced, stimulating world in pharmaceutical revenue management and marketing needs H1-B visa assistance to hire the kind of expert that is not available in sufficient quantity or quality to allow efficient pursuit of medical excellence. In past years, such personnel were to be found only in select industries such as tobacco and other personal care products. Building the right team, with applicable key performance indicators and mission-critical elements, is too important to be left to chance so every avenue must be explored, every base touched. Consumer options are opened up in the free market of healthy competition for products rather than stifled under excess regulatory and legal layers.

That kind of expert. /s

Jon S , March 20, 2018 at 12:34 pm

I really enjoyed that!

sgt_doom , March 20, 2018 at 1:54 pm

Man oh man!!!!

Had a deja vu moment there -- thought I was back as an employee during a leveraged buyout by the typically sleazy PE firm of Baird Private Equity!!!!!

Lambert Strether , March 20, 2018 at 7:07 am

Sounds like Soloviev wasn't a "smart shopper"!

Miamijac , March 20, 2018 at 7:28 am

Teatree oil, anti fungal. >$3.00. They only have a license to practice.

Croatoan , March 20, 2018 at 8:17 am

Just be careful with the natural stuff

"The results of our laboratory studies confirm that pure lavender and tea tree oils can mimic the actions of estrogens and inhibit the effects of androgens ," said Korach. "This combinatorial activity makes them somewhat unique as endocrine disruptors."

https://www.nih.gov/news-events/news-releases/lavender-tea-tree-oils-may-cause-breast-growth-boys

Kevin , March 20, 2018 at 9:06 am

My wife is a massage therapist and dispenses oils occasionally. NEVER use straight oils – ALWAYS use a carrier oil in conjunction.

BTW – anyone else notice the toe fungus ad placed above the comments we're being watched!

oh , March 20, 2018 at 3:14 pm

Another myth propagated by the hand maidens to the Pharma industry.

cnchal , March 20, 2018 at 8:29 am

The title of the post is a bit misleading.

It should have been "Bill Of The Month: For Toenail Fungus, A $16,500 Prescription and less than 10% effective".

. . . She began swabbing it on the two toenails, as directed, having been told it would take about 11 months to treat the fungus .
– – – –
Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill . . .
– – – –
In its application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.

The post's title diminishes the scale of the scam by a factor of at least 100.

sgt_doom , March 20, 2018 at 1:55 pm

Very well articulated and thought out!

Props and kudos!!!

lyman alpha blob , March 20, 2018 at 3:52 pm

That last bit blew my mind. Why in the hell is the FDA approving anything as a treatment that can only be shown to cure what it's supposed to less than 10% of the time!?!? And we know how the approval process scam works – the companies only submit the best results in the first place and leave out the data the shows treatments to be less successful.

That being said, who would like to try out my new wonder drug? It cures absolutely everything that ails you at least 5% ot the time. I call it Plaisibeaux – the ingredients are French and they're a trade secret. Any FDA employess around who can fast track this one for me?

Joel , March 20, 2018 at 8:35 am

My simple stupid solution just avoid them entirely, the docs the tests the meds the hospitals. Advil is cheap and works for most of the pain. A couple of other basic meds for occasional random stuff that I buy when I travel outside the US. Try to work out a bit and eat more or less right. Except for easy obvious stuff I never met anyone that actually got better by going to a doctor. When its time to die I guess I will die.

Stillfeelinthebern , March 20, 2018 at 2:43 pm

X1000

Couldn't agree more.

oh , March 20, 2018 at 3:16 pm

+1

sierra7 , March 20, 2018 at 10:00 pm

In our healthcare system (and I guess totally), when you're healthy you're wealthy!

mark , March 20, 2018 at 8:35 am

It's really worse than the article suggests. Kerydin (tavaborole) isn't even all that effective. In one trial, "cure" was achieved in about 7% of cases and in other trials "completely or almost clear nail rates" were achieved in 15 – 30% of cases:

In clinical trials, tavaborole was more effective than the vehicle (ethyl acetate and propylene glycol) alone in curing onychomycosis. In two studies, fungal infection was eliminated using tavaborole in 6.5% of the cases vs. 0.5% using the vehicle alone, and 27.5% vs. 14.6% using the vehicle alone.

https://en.wikipedia.org/wiki/Tavaborole#Therapeutic_trials

For those interested, this is the original paper that the Wikipedia entry is based on:

https://www.sciencedirect.com/science/article/pii/S0190962215015121

Thomas Briggs , March 20, 2018 at 9:14 am

Last visit was a snake bite. Antivenom was about 60k. Pretty sure same can be had in Mexico for less than $1,000, maybe much less. That was 5 years ago. I refuse to participate any longer, & I have good insurance. I hope eating better, exercise, & homeopathic treatments can work for me. Have not seen a doctor since & won't unless taken unconscious.

oh , March 20, 2018 at 3:18 pm

Agree with you. Eat healthy foods, exercise, homeopathic or ayurvedic treatment when absolutely necessary. No need to go for their "free" physicals. Listen to your body.

Pat , March 20, 2018 at 9:19 am

So a physicians assistant diagnosed a fungus strictly on observation, calls in a prescription for an ineffective and more difficult to use but massively expensive prescription and it is the patient's fault.

Don't know about the rest of you, but I see at least three problems in that that have nothing to do with the patient OR even the obscene greed of the pharmaceutical industry but a whole lot with the Braun Dermotological Center.

XXYY , March 20, 2018 at 10:32 am

I have no proof, but my guess is that these medical centers have sweetheart deals with mail-order pharmacies for various overpriced drugs. We took my son to a dermatology place several times for acne treatment; they would commonly propose something I had never heard of and urge us to order from a particular mail-order pharmacy, often providing coupons. I saw no reason not to get it from our local pharmacy but they were strangely insistent on us doing it by mail.

One obvious problem with mail-order pharmacies is made clear in this piece: by the time you find out how much things cost, it's already a done deal. At a retail pharmacy, you can walk away without paying. This is obviously a feature of mail-order pharmacies, not a bug.

Kevin , March 20, 2018 at 11:02 am

The proliferation of specialty medical centers around the western Chicago suburbs has been amazing to witness – similar to the proliferation in the number of bank outlets prior to the crash

Katniss Everdeen , March 20, 2018 at 11:33 am

No kidding. How is prescribing a drug, even a cheap one, that's "effective" only 7% of the time even considered medical "treatment?"

And what in the world is that "statement" pictured above? It's flat out false. Is it somehow supposed to be official? Where did it come from?

"Total Rx cost" in January: $56.52???? No, it was $1,496.09–same as in February.

"You paid" (Patient paid?) in January: $56.52? No, the patient paid $1,439.57, "funded" through her HRA and shown with an asterisk at the bottom. $56.52 was apparently a drug company rebate / coupon.

About the only true thing in January was that the insurance paid $0.

The "You paid" in February was not, in fact paid by the patient, but by another drug company rebate / coupon. She was not even asked to write a check for the copay, an expense she would have expected.

The "Your Cost" of $620.43 at the top appears to be the sum of the two drug company coupons for January and February, although no time frame is specified. At this point, the patient had written NO checks, even for the copays.

As an aside, where is the $60 "Copay/Co-insurance for January?

The patient's actual "cost" over the two months would most accurately be represented as the sum of the two months' Rxs–about $3000–plus two $60 copays. "You Paid" should be what she actually paid, either out of pocket or through the HRA, and any fees or copays that were covered by drug company rebates should be clearly noted as CHARGED but ABROGATED.

I'd suggest that deliberately confusing and understating seemingly obvious terms such as "cost" and "paid"
deliberately obfuscates the situation in order to sell expensive drugs that people would balk at purchasing if they knew the true "cost."

And all of this is before figuring out, for a Medicare recipient, how all these worthless, expensive drugs, coupons and rebates propel the patient toward the "donut hole," an entirely different kettle of fish in which nobody pays for nuthin' except the patient.

Joel , March 20, 2018 at 4:45 pm

+1 These "statements" web pages or whatever are designed by either morons or sadistic fiends. Probably the same ones that design cell phone bills

anonymous , March 20, 2018 at 9:48 am

This reminds me of the time I was billed $300 for a foot splint by a podiatrist that my insurance refused to pay for. I could have bought a foot splint off Amazon for $30.

Always ask for prices for any treatments or medicines. I trust my dentist way more than any doctor I've been too.

vidimi , March 20, 2018 at 10:05 am

this stuff is free in france for anyone with a social security number

Bugs Bunny , March 20, 2018 at 10:46 am

Kerydin has not been approved by the European Medicines Agency. You shouldn't state things as fact unless you can back them up.

Jon S , March 20, 2018 at 12:40 pm

I'm sure he meant "medicine that fixes toe fungi" is free in France, not Kerydin. And of course Kerydin isn't approved in Europe, with a 7% efficacy rate, it's doesn't really have medicinal value. It would only be prescribed in the US.

crittermom , March 20, 2018 at 10:15 am

Stories such as this are infuriating.

I went to a Podiatrist a couple years ago for a different problem but mentioned I thought I had a toenail fungus, too.

The Dr confirmed that but instead of prescribing something he recommended coconut oil. He said it worked much better & faster than any pills he could prescribe & he was right.

I had a large jar of solid coconut oil (around $6) & applied it with a Q tip.
In very short time the fungus was gone.

A girlfriend had gone to her Dr who prescribed pills.
Her fungus returned within a few months.
Mine hasn't.

Lord Koos , March 20, 2018 at 1:08 pm

This is not surprising – before I read your post I was thinking, there is probably a simple home remedy for that condition. There are a lot of useful drugs out there, but there are probably just as many that are useless, ineffective, or that have dangerous side effects and unintended consequences. I took over-the-counter anti-allergy meds for my hay fever for years, only recently reading that they (Claritin, etc) are now implicated in the onset of Alzheimer's. Thanks a lot

JamesG , March 20, 2018 at 10:41 am

I caught a similar prescription with a high co-pay and refused to pick up the merch from the pharmacist.

I then treated my fungus with Lamisil an OTC product which works for me.

Steve Roberts , March 20, 2018 at 10:42 am

I was written a script for a tube of cream that supposedly cost nearly $3k. It's hard to know what the pharmacy benefit manager actually paid because they are pretty secretive about that sort of thing. Per a friend she estimated it at probably $50 which is still idiotic. It was an anti-itch cream and wasn't any better than a $2.50 tube of cortisone cream.

otis , March 20, 2018 at 11:22 am

For the love of Pete. Isopropyl alcohol costs $1.79. Cut your toenails then apply with q tip. No more nail fungus. One bottle = many years supply.

I'm amazed people will take pills to cure nail fungus. So Dumb.
$14.000 annual toe cream. Dumb dumb dumber.
Thanks for posting these absurd bills. It lays bare the financialized health care holocaust underway in the USA.

perpetualWAR , March 20, 2018 at 11:32 am

Toenail fungus? Get apple cider vinegar.
Why do people not first look at home remedies?
Apple cider vinegar clears that up in a snap.

Synoia , March 20, 2018 at 11:49 am

Fungus can be treated by soaking in a 25% solution of vinegar, twice a day for two weeks.

Change the pH, kill the fungus.

That was my prescription for a fungus on my foot, by my doctor. And it worked.

Fred , March 20, 2018 at 1:00 pm

I pay less for my medicines when I pay cash as the pharmacy gives me a discount. But, because Part D has a penalty for not enrolling, I use it for 5 of medicines and then pay cash for one of them and pay about $5 more per month. Not to mention my doctor offered to do my stints for half price if I paid for cash. The whole healthcare system is a mess.

Pogonip , March 20, 2018 at 1:16 pm

I don't know about other countries, but here in the U.S. you should always, always, always assume that in any transaction you engage in, the seller has been financialized and will actively try to squeeze more money out of you, the ideal being to take all your available money and give you nothing in return. Be wary.

There are plenty of honorable exceptions, like the honest doctors and the mechanics described above. Cherish those sellers, patronize them, spread the word of mouth, especially if you think capitalism is the best of all possible economic worlds. The rent-seekers, if they continue unchecked, will destroy capitalism, because it requires some minimum level of trust to work. The odds that the seller will provide a good product or service have to be at least better than even.

Anonymous , March 20, 2018 at 1:54 pm

Philia is a necessary casualty of identity politics. Society depends on the collective will of people to take actions that are not in their direct benefit because they know others will make them. The "Tragedy of the Commons" does not occur when philia is strong because people know they can trust others not to abuse common resources. Once people do not trust others to act for the greater good it is a race to the bottom. The problem with identity politics is that it creates distrust of others outside ones own identity group as 'others' who cannot be trusted.

jrs , March 20, 2018 at 3:51 pm

oh yes identity politics created that, as if there wasn't far stronger prejudice by dominant groups long before identity politics was even a glimmer in it's dad's eye.

CrosslakeJohn , March 20, 2018 at 3:12 pm

Ten years ago or so in Corte Madera California, I was very lucky to find a podiatrist who was doing research on toenail fungus. I had nine of ten toe nails involved, some since high school (so for decades). His protocol for this was
1) pulse dose of two Lamasil tablets at the start of treatment
2) OTC bottle of fungoid tincture (with little brush built into the cap) from drug store with half a Lamasil tablet dissolved in it
3) every morning in the shower, scrub the nail ends with a toothbrush and a chlorine powder cleaner like Comet
4) brush a small amount fungoid tincture onto nail ends after morning shower and at night before bed.
5) keep nails short with clean cut ends

As I recall, the Lamasil pulse dose kills the fungus in the nail bed right away, and the fungoid tincture wicks into the nail every time and carries the anti-fungal drug to the fungus residing within the nail. The chlorine cleaner acts as a dessicant and pH modifier.

Ultimately, he gave me the few necessary Lamasil tablets as free samples, and back then the fungoid tincture was maybe $4/bottle at walgreens.

The new nails grew in from the nail beds perfectly, and after many months I had perfect toe nails and ceased treating them. They have remained so ever since.
I have always wondered if this approach was ever published in a medical journal. No significant money to be made from it by the manufacturer of Lamasil, so it's hard to see who had an incentive to promote it.
Disclaimer: I am not a doctor and am not giving medical advice. Pursue at your own risk.
Thanks!!

rps , March 20, 2018 at 4:48 pm

Why your pharmacist can't tell you .
WASHINGTON -- As consumers face rapidly rising drug costs, states across the country are moving to block "gag clauses" that prohibit pharmacists from telling customers that they could save money by paying cash for prescription drugs rather than using their health insurance The pharmacist cannot volunteer the fact that a medicine is less expensive if you pay the cash price and we don't run it through your health plan ."

The White House Council of Economic Advisers said in a report this month that large pharmacy benefit managers "exercise undue market power" and generate "outsized profits for themselves."

P Fitzsimon , March 20, 2018 at 4:57 pm

I'm going to get in trouble for saying this but toenail fungus isn't exactly leprosy. I've had a case continuously for 40 years after damaging my toenails in an accident. About 20 years ago I went to a doctor to see what could be done to get rid of it. He said I can give you a prescription that may cure it . But would you rather risk your liver or take the fungus with you to the grave after a full and healthy life with the fungus. I dont know what it would have cost because I chose the fungus. If it had cost $1500 and he hadn't told me the cost I would have been most unhappy.

Bill Carson , March 20, 2018 at 6:09 pm

This is shameful and absurd. However, the article mentions that there are "pills" that can be prescribed to treat the toe fungus, but some people taking those pills (terbinafine aka lamisil) have developed severe liver damage leading to liver transplant or death.

How much does it cost to just remove the toenail?

Bill Carson , March 20, 2018 at 6:28 pm

Why does this prescription cost $1,650 per month and not $16,500? Or $165,000? Or $1,650,000? Who decided that $1,650 was reasonable and $1,650,000 wasn't?

Bill Carson , March 20, 2018 at 6:46 pm

Oops, I meant $1,500 per month. But it probably costs more now anyway.

And how do they make an ointment last only a month? I've got some ointments under my sink that are 30 years old.

Bill Carson , March 20, 2018 at 6:39 pm

I'm a lawyer. I took Contracts 25 years ago in law school, but I seem to remember that there are certain elements to a contract that have to be present before the parties can be bound. Let's see

1. Offer
2. Acceptance
3. Consideration
4. Mutuality

Now, it seems to me that Consideration can't just be left blank. It is a very rare (non-medical) contract indeed where the buyer says, "I want X, no matter what it costs."

If I stay at a hotel and they have a mini-fridge with various refreshments and snacks, and I take a Diet Coke and a Milky Way, they can't legally charge me $10,000 for that.

I don't know why this isn't considered defrauding the consumer. We should be able to sue the crap out of these companies.

mtnwoman , March 20, 2018 at 7:40 pm

Give the medical practitioners a break! So now they need to puruse the Wall St Journal daily to see what pirate has acquired what formerly cheap generic drup to monopolize it and raise the price 500%?

Yes, the price was outrageous. How is the practitioner supposed to know every patients health care coverage and what one particular insurance carrier will cover for what drug? What's $50 for one person is $1500 for another, depending on their insurance.

Our entire health care system sucks. The only people who like it are the Insurance and Pharma execs.

Tim , March 20, 2018 at 9:09 pm

I won't give a doctor a break that prescribes a non-essential medicine with a 6% success rate.

[Mar 17, 2018] How to negotiate directly with physicians and hospitals

That's a fantasy: "It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount" Many hospitals sells you to collection immediately.
Mostly this is a cheap self-promotion of a yet another snake oil salesmen... Some more tidbit still might be useful You are warned.
If you try to fight medical-industrial complex alone most of the time you will be crushed. As a minimum you need a legal help. Often you need insurance too: at the end it is cheaper to have insurance then to fight astronomic bills. But those bottom feeders still can get to you via balance billing. and in most case, when you stay in hospital they do get back to you with the additional biils. That's why you will need a lawyers to fight this.
The usual trick of this scammers is to get "out of the network" ambulance and bill you $5K or more. Even the transfer from one hospital to another via ambulance can cost you tons of money.
Unnecessary procedures is another important danger. Stents is one such danger, in case of suspicion for the heart attack. You can get several several of them even if do not need them as a courtesy of those greedy jerks ;-)
And they will never agree for Medicare rates. Forget about it.
Notable quotes:
"... As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts: ..."
"... You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well. ..."
"... The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required. ..."
"... Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable. ..."
"... Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment! ..."
"... Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions. ..."
"... I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described. ..."
Mar 17, 2018 | www.zerohedge.com

... ... ...

Approximately 63% of Americans have no emergency savings for things such as a $1,000 emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000 adults by personal finance website Bankrate.com, up slightly from 62% last year. Faced with an emergency, they say they would raise the money by reducing spending elsewhere (23%), borrowing from family and/or friends (15%) or using credit cards to bridge the gap (15%).

http://www.zerohedge.com/news/2016-01-07/sad-state-affairs-two-thirds-a

... ... ...

You are going to need five things, which I am going to give to you, today, free of charge!

  1. Some absolutely critical industry vocabulary
  2. A clear understanding of how healthcare is priced in the USA
  3. Insight into to actual pricing
  4. A proven negotiation strategy, including:
    • a. The point of contact
    • b. Foreknowledge of what prices medical providers will usually agree to
    • c. A sample offer and agreement
  5. The confidence to successfully negotiate

Unfortunately, I couldn't come up with a better way to impart to you an understanding of the industry lingo, other than these simple handouts. However, this information is so important for you to be able to understand any negotiation strategy that I simply must slog through each term with you now. Please, I ask that you hold your questions and comments until I get through the vocabulary. Many of the terms are cross-referenced, and will become more clear after we here them all.

... ... ..

To begin to understand how healthcare is priced, we are going to look at

  1. the doctor's bill given to a patient,
  2. the claim forms the doctor and hospital send to the insurance carrier, and
  3. ERAs that the insurance carrier then send back to the patient and the providers.

As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts:

On the hospital's bill you might see something like this:

It is important to understand that the amounts shown on both of these bills are un-discounted Billed Charges (Usual and Customary Fees). They are the highest price the provider might ever hope to receive for the service, also known as full retail, or MSRP. Don't panic when you get these bills, because as everyone knows, "Never pay retail."

You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well.

If you have insurance, the providers will send your carrier a claim with essentially the same data as is on the bill they will provide to you if you are not insured, or if you simply request a copy.

An important fact is that Federal Law, as a requirement for the medical provider's participation in Medicare, requires that a medical provider charge every patient the same amount for a given CPT item. What it does not require, however, is that a medical provider accept the same payment amount from every patient for a given CPT item. This allows insurance companies, government payers, and you to negotiate a discounted fee, known as a contracted allowable, and not be in violation of the law.

The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required.

This creates a tiered-pricing structure for medical services that looks very much like this table in your handouts:

At this point, if you are paying close attention, then it should start to dawn on you where I am leading you with this talk, which, after all, is titled: How to negotiate directly with physicians and hospitals.

Spoiler Alert: You are learning how to negotiate for Medicare rates, at worst, and Medicaid rates, at best. In our example, a bilateral elbow fracture patient in Texas received surgeon and hospital bills totaling $179,219. Medicare allows $30,542 and Medicaid $22,600, which means the government negotiated an 83% or 87.4% discount, respectively. You can too!

Before we move on to providing you with access to these fee schedules, and then a negotiation strategy, do you have any questions about how healthcare is priced in the USA?

Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable.

Quick show of hands: how many of you have received a medical bill, or an EOB, and threw it away because you could not understand it? That is intentional! They want you to be confused. However, after today, I doubt that you will ever do that again.

What if we do not have insurance, or we want to know the allowable, because we think this is important information to know so that we can negotiate before receiving healthcare? Think having a baby or elective surgery. Do not worry! The federal government provides us with the Medicare rates online, and I believe that each state provides its Medicaid fee schedules online.

You would soon discover, however, that it is much easier to determine the allowable for a physician service than a hospital service, for which you will likely need to look up the DRGs for the ICD codes and then try to cross-reference them with the IPPS Fee Schedule, at a minimum, or you may even need to look up and calculate conversion factors. It is not easy, again, intentionally so!

Regardless, we would first need the CPT codes for the services you are seeking from the physician, and probably the ICD codes, too, in order to price hospital services. You could try to guess at the diagnosis and the services you think the doctor is going to provide to you, and then try to use a search engine to determine the ICD codes and CPT codes, or buy a coding book.

"I know I need a hip replacement. My trainer at the gym told me so. I'll just Google, hip replacement ICD and CPT code."

Good luck with that! The odds of you guessing the correct diagnosis and appropriate procedures (without going to medical school) are incredibly slim, especially with the new ICD-10 diagnosis codes. Also, chances are good that your athletic trainer doesn't know what the hell she is talking about when it come to medicine, and in reality, you probably just need a new athletic trainer, and not a new hip.

Is your head spinning, yet? Good! Now, stop it, because you will see that we don't need to do any of that! It's all just a red herring designed to keep us confused and the health insurers in business and profitable. Sounds a lot like our banking system, no?

Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment!

You may be thinking, "Isn't that putting the cart before the horse? Don't we want to know the costs in order to negotiate the fees before the services are provided?" The surprising answer is, no! Why? Well, because we only need to negotiate the fee schedule, specifically, Medicare or Medicaid, and not the exact fee. This is very important. Think back to the tiered-pricing structure.

Eventually, we may want to know the actual (or sometimes estimated) allowable amounts in order to budget for elective procedures, but this occurs after, or at the time of the physician's office visit, when they can provide us with the ICD codes, CPT codes, and usually the allowable amount, too! Later, we may choose to audit the allowable amount they give us, to make sure it is correct, and we were not over charged, but this is seldom done, as most people still trust their doctor, and the discounts you will be receiving are so HUGE you may feel a little guilty. Also, I will tell you, the auditing process is very tedious, not to mention the appeal process.

Therefore, we are now going to start talking about a negotiating strategy before we even attempt to access any pricing data. Again, we first need to know the diagnoses and proposed treatments. So, the solution is to start with a simple negotiation with the physician's office, probably just for the cost for the initial office visit, at the very least, and maybe some expected diagnostic tests. This is best done over the telephone, is easier and more successful than you might think, and is analogous to finding a mechanic to, "just take a look," at your car and tell you what is wrong with it, and then getting an estimate to repair it. Just like we expect to pay a little bit for the mechanic to diagnose our car, we should expect to pay a little bit for the doctor to diagnose us. The funny thing is that my mechanic and Medicare both charge or allow about $100 for a diagnosis. This is not so funny if you are the surgeon that spent 13 more years in school than the auto mechanic with a high school diploma.

Here we go, step by step:

1) I usually prefer to skip the added expense of going to a GP or family practice intermediary just to get a referral to a specialist that can actually help, especially when I can determine what medical specialty is likely to be most helpful for by medical condition by visiting the website of the American Board of Medical Specialties. (Is your ignition system acting up, your suspension riding a little rough, need new tires, brakes squeaking, transmission grinding?)

http://www.abms.org/member-boards/specialty-subspecialty-certificates/

2) Use the links on abms.org to visit the appropriate specialty board's website, and then use their "find a physician" with the sub-specialty likely to be most helpful for the condition

3) Start calling the sub-specialty physician offices listed, tell them you are a prospective new patient, and ask to speak to the Business Office Manager. Ask him or her the following questions:

a) "Do you accept Medicare and/or Medicaid insurance?" If yes, then...

b) "Super! Do you accept cash payment at the time of service?" If yes, then...

c) "Great! Then, of course, you will accept as payment in full, the Medicaid allowable, but paid in cash by me to you, directly, at the time of service? Correct?" If yes, then (e). If no then (d).

d) "I guess I understand. Well, then surely you will at least accept as payment the Medi­care allowable, paid in cash by me to you, directly, at the time of service? If yes, then (e). If no then conclude the call, because you cannot fix stupid.

e) "Thank you! Can you please tell me what the estimated amount is for an office visit, using this fee schedule, so I can know how much money to bring, and please make a note on my account that we have negotiated a Single Case Agreement for me to pay these rates to you, in cash, at the time of service?

f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor of my garage) and that you want to be fully prepared for the visit. Ask what diagnostic tests, if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc., and which ones would probably need to be done outside the physician's clinic?

g) Make sure to get the BOM's name and contact information, and the appointment time and date.

After your office visit, if it turns out that you need a procedure such as day surgery at an Ambulatory Surgery Center (ASC), an inpatient admission at a hospital, a diagnostic test like an MRI or CT, or a series of treatments such as physical therapy, then you simply repeat the above negotiation, starting with the facility your physician recommends, and in the case of a hospital or ASC, always where he or she has privileges. ASC's allowable rates are always much lower than a hospital, so act accordingly. When telling the BOM that you are a prospective new patient, make sure to give the name of your physician. Instead of just making a note of any negotiated agreement in your account, the BOM and you should execute a written Single Case Agreement. It is usually a one-page agreement that looks something like this sample found in your handouts:

It should be obvious to you why, when possible, these negotiations should occur before treatment, which is more often than you might imagine. In general, elective conditions are negotiated in advance in this manner. Next, we are going to look at emergency conditions, which are more than likely negotiated after examination and treatment.

Before we do, are there any questions?

Ok, so I experience some kind of true medical emergency, where my life or limb is in jeopardy, like a heart attack. mrs_horseman puts me in an ambulance that rushes me to the Emergency Room at the hospital, and they run all kinds of tests, and give me some very expensive medications. Fortunately for me, a long enough timeline has not yet passed, my survival rate has not dropped to zero, and I don't even get to go to the cath lab or have emergency heart surgery. However, we do get several large medical bills from the hospital, ER doctor, ambulance, laboratory, and cardiologist. I either have no insurance, am self-insured, or I have a catastrophic insurance plan with a very high deductible that I am not likely to meet with this event, or this year. What do I do?

When I receive each bill, I immediately call each provider and get the name and address of the BOM. I then draft a Single Case Agreement Offer and Acceptance, and I offer to pay the estimated Medicaid allowable clearly labeled as such (by using the tiered-pricing structure I covered earlier) and expiring 10 days after it is received. I may also include some horseshit narrative about how I just received a small windfall, and was advised by my attorney to settle my hospital bill before I piss it away on fast women and slow horses, or worse, squander it. I send this to the BOM, Certified Mail-Return Receipt Requested , with my attorney copied on the bottom of the offer. The BOM may argue the accuracy of my Medicaid estimate, and make a counter offer with a more accurate Medicaid allowable, but the odds are very, very, high that he or she either agrees to the Medicaid allowable, or counters with something like a Medicare allowable. Either way, at this point I have successfully negotiated somewhere around an 83% - 87% discount on average, less for doctors, more for hospitals.

It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount, and far better than a healthcare provider at actually getting blood from a turnip. Medical providers are now turning their accounts over to collections as soon as 90 days from the date of service, which can mean that you are still being treated for this condition when this happens! Do not let this happen to you! Open the bills! Mail the offer! Maybe they say no, but that is not likely. On the other hand, the collections agencies are working very hard to get you on a payment plan for Billed Charges, with interest, for the rest of your life!

Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions.

There it is. I said it. Think about that for a moment.

Now, considering the minimal risk of negotiating, and the large potential reward, do you now have the confidence to successfully negotiate directly with physicians and hospitals?

Before I spend just a few more minutes talking about pharmacies, and then finally some self-insurance goals, are there any questions or comments?

I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described.

Are you ready? Coupons and free discount cards. He explained that if one simply goes online and searches for Walgreens coupons, it is usually possible to save between 5% and 60%. He specifically recommends Good Neighbor Pharmacy Prescription Savings Club.

http://www.mygnp.com/prescription-savings-club

He says that when you purchase medications, then you have 5 days to return to the same location Walgreens and bring a coupon for reimbursement of any savings. He says that if you are paying cash, then you must be sure to request a generic, if available. For long term meds, he explains that the drug manufacturer's web sites will often offer a free co-pay assistance card. If you have insurance, then you can present the free card from the manufacturer to the Walgreens pharmacy, and it will cover your co-pays. In closing, I want to talk just a bit about insurance and one of the situations where we would want to be able to negotiate directly with physicians, hospitals, and pharmacies.

As we have discussed, today, one of the primary benefits of having health insurance is to take advantage of the discounts negotiated by the insurance company or government. However, we just learned that providers are usually willing to accept similar discounted rates from cash pay patients.

The other big benefit of health insurance is to share with other people the risk of having to pay large bills that are the result of serious and unexpected injuries or illnesses. This is the traditional role of insurance. However, the costs and benefits of sharing risk are directly related to the health and healthcare consumption habits of all the members of the risk pool. As the post-vasectomy head of a healthy household, do I really want to be swimming in the Obamacare risk pool with millions of morbidly obese, perpetually pregnant, HIV infected drug abusers? No. It is too expensive!

What to do? Well, what do many smart employers in Texas do to save money with Worker's Compensation Insurance? They self-insure! They have money put away in case of an emergency. If they have an employee that is injured, then they negotiate directly with the healthcare providers, and pay deep discounts well below the statutory Worker's Compensation allowable, which we learned earlier is usually the highest allowable. They pay themselves a premium each month, which is effectively a forced savings plan. Sometimes, these companies may also purchase a relatively inexpensive health insurance plan called catastrophic, just in case a really big and expensive event occurs, like the whole oil refinery blows up and puts a few hundred employees in the hospital. However, if nothing happens, and the employees don't have any accidents, the company gets to keep most of the money, instead of giving it all to the insurance companies!

Hmmm. I wonder. Could I do that for my health insurance? Yes, and in fact mrs_horseman and I do exactly this. We have a high-deductible catastrophic health insurance plan and a $600 savings line item in our budget that we pay ourselves every month. We bet on ourselves to be healthy, unlike an HSA, where you bet on yourself to be unhealthy. This is true, and why we simply refuse to take the pre-tax bait of an HSA.

... ... ...

[Dec 05, 2017] A coalescence and consolidation of insurers effectively being single-payer, expensive private sector paying monopoly. This by-and-large parasitic industry consumes add 35-40% tot he costs feeding whose executives and employees do not contribute constructively to the CARE equation

Notable quotes:
"... Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE. ..."
"... I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. " ..."
"... Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.] ..."
"... The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels. ..."
"... Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence? ..."
Mar 23, 2017 | www.nakedcapitalism.com
djrichard, March 22, 2017 at 5:35 pm

Just a bit of a thought experiment, building on some thinking from a comment yesterday by jefemt

Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again -- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE.

Conceivably, it wouldn't even have to live off appropriations from congress, assuming it was equally as extractive from the private sector as it is now (i.e. revenue model is the same). Talk about good living. Who knows, maybe they pocket their proceeds into some kind of surplus in Treasury dept.

But let's assume they had to give up on revenue models. [Afterall, it's easier to find partners in congress when you have an appropriations process that binds you to them.] Then they would be exposed. Somebody would get the bright idea that this agency doesn't need as much staffing since they are no longer revenue oriented. That indeed, they could have the same staffing profile as the agency responsible for medicare. Indeed they could be folded into medicare.

I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. "

Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.]

In contrast to other parts of the deep state that don't really have a revenue model. In which case, those parts need to be insourced by the Fed Gov.

human , March 22, 2017 at 7:46 pm

The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels.

Ernesto Lyon , March 23, 2017 at 12:09 am

Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence?

[Nov 30, 2017] Healthcare Costs and Its Drivers Today by run75441

Notable quotes:
"... We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ..."
"... Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume. ..."
"... In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents. ..."
"... Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA ..."
"... So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. ..."
Nov 25, 2017 | angrybearblog.com

I have been doing my typical reading on healthcare in the US and ran across several articles which seemingly come together at various points in the dialogue and are written by different authors. I decided to tie them together into a much wider and telling story.

An interesting point being was made by MedPage Today's Dr. Milton Packer on his blog, " people suffer and die because Payors (Healthcare Insurance) is cost effective ." He starts his discussion on the opiate epidemic in the US, opiates are being prescribed by doctors for pain relief and . . .

"Patients are becoming addicted to opiates after the initial 10 day prescription with one-fifth of patients still using opiates a year later. There is no need to prescribe opiates as other less addictive pain-relief formulations are available, which are not commonly prescribed." This raises the question of why?

Payers will not pay for the alternatives. The less-addictive opiates are more expensive and payers have declined to support them. Patients get addicted because prescribing for the lower cost and highly addictive opiates saves the payers money initially (me) .

September 17, 2017, the New York Time and ProPublica (independent, nonprofit investigative journalism organization) collaborated on an article concerning the opiod epidemic in the US.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason given: Opioid drugs are generally cheap while safer alternatives are often more expensive.

While the pharmaceutical manufacturers, distributors , and doctors have come under scrutiny; insurance companies and the pharmacy benefit managers (CVS Caremark, Express Scripts and OptumRx) make the final decisions as to what is covered. It could be something as simple as a higher tier and deductible to block usage.

A little side trip here and a continuation of the above. A week or so ago, I ran across another MedPage Today article by Dr. Packer; " Who Actually Is Reviewing All Those Preauthorization Requests and How the System Works ." Dr. Packers was giving a talk on advances in medicine with regard to heart failures to a room of about 20 or so doctors who were retired.

Since many of them were no longer involved in active patient care, he wondered why they might want to hear a presentation on new advances in heart failure. Here was their answer:

Doctors: " We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ."

" Dr. Packer: I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients? "

The answer; "Yes."

" So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities? "

"Oh, we've heard about those drugs before. We are asked to approve their use for patients all the time; but, we don't approve most of the requests. Nearly all of them are outside of the guidelines we are given."

" I just showed you evidence that these new drugs and devices make a real positive difference in people's lives. People who get them feel better and live longer. "

"Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."

" If the drugs will help people, how can you say no? "

"You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare."

" But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need. "

"You really don't understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare."

"Plus, if I approve too many expensive drugs, I won't get my bonus at the end of the month. So giving out too many approvals wouldn't be a smart thing for me to do. Would it?"

Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume.

In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents.

Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA .

Furthermore with the consolidation happening in healthcare, negotiation by insurance companies with a consolidating and growing healthcare industry is becoming more and more difficult as the former does not have as great of leverage. You have read my argument calling out of Single Payor, Medicare-for-All, Public Option, etc. as the cure for today's healthcare issues and rising cost not being enough as the ACA and Part D were specifically blocked or the cost issue unaddressed in the legislation written by Congress. If these issues are not addressed from the very beginning, we will be fighting the same issues with rising costs a decade later with other programs.

At this point, I begin to disagree with Dr. Packers as he goes on to say:

" So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. "

It is true that patients may not get some of the healthcare they need at the time due to denial, which can be appealed to the ACA, and can be a tiring process. It could be approved, passed on to patients, resulting in higher premiums the following year, and the Part D Risk Corridor program pay for it if excessive for the present year. What Dr. Packers does not mention is the rising prices and cost of drugs being blamed by pharmaceutical company on R&D, tooling up to manufacture, etc. The counter argument is much of the R&D is funded by the US government through tax deductions and write-offs for pharmaceutical R&D and capital Overhead. Pharmaceutical profits are double digit at ~25% beating out hospital supplies and healthcare insurance, which is already limited in what can be charged back to the insured by the MLR. To blame insurance companies totally for the higher costs in healthcare is false. Furthermore, a doctor's decision do not always lead to less costly cures or practices.

Maggie Mahar of Health Beat Blog would take the subject of costs a step farther and state Medicare will approve anything the FDA approves for usage regardless of the quality of outcome when measured against older proven treatments. Notably the VA does limit its pharmacy and its care is rated higher than that of today's commercial, for-profit healthcare to which most citizens are exposed.

Dr. Donald Berwick, President Obama's proposed appointment for Medicare and who was in charge of Medicare and Medicaid for 17 months stated;

"20 to 30 percent of health spending is 'waste' that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by Medicare and Medicaid.

He listed five reasons for what he described as the 'extremely high level of waste.' They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud .

Much is done that does not help patients at all and many physicians know it."

That is the same Medicare/Medicaid being touted by many proponents today as an alternative.

Speaking of costs and pricing for pharmaceuticals, there have been recent incidents of skyrocketing costs on particular drugs. A short while ago, I wrote a post concerning the appointment of Alex Araz as the new HHS Secretary replacing Dr. Tom Price. Formerly, Alex Araz was the CEO of the pharmaceutical giant Eli Lilly & Co.'s U.S. division . He also served under George W. Bush administration as the HHS General Counsel and Deputy Secretary. During that stint, he received praise for his management competence with the HHS; although, he did not have a healthcare background prior to this position.

Here it gets interesting when examining what took place during his tenure with Eli Lilly. One of the leading costs identified in pharmaceuticals increases has been in the rising cost of diabetes medication.

"While the Tweeter-in-Chief, Trump tells us presidential campaign contributor Alex Azar will be a 'star' who will lower prescription prices,"

Public Citizen's Peter Maybarduk (Director) had this to say: " Eli Lilly is notorious for spiking prices of a century-old isolated hormone during Azar's tenure as president and vice president. Eli Lilly raised the price of Humalog by 345%, from $2,657.88 per year to $9,172.80 per year.

Maybe President Trump in appointing Alex Azar to be HHS Secretary should have asked the 6 million diabetic Americans whose insulin prices have more than tripled under Azar's watch at Eli Lilly."

This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and throughput restricted manufacturing (capacity).

What I have tried to do is tie these articles together into one cohesive story of how the pharmaceutical industry, insurance, and healthcare can have an impact on healthcare costs. For those who are interested, my background does include working in the manufacture of hospital supplies and pharmaceuticals. Using various citations from these articles, I have tried to touch upon the impact of insurance companies, the healthcare industry, government intervention under the HHS, one particular Med in the market place, etc. Overall, what is going on in the marketplace.

Another article, I read the other day gets into the foundation of what is happening based upon a recently completed study by JAMA. Using this study, the Methods Man, Dr. Perry Wilson (MedPage Today) examines what is driving healthcare costs in his article Here's What's Really Driving Healthcare Costs using data from Factors Associated With Increases in US Health Care Spending, 1996-2013 and the US Disease Expenditure Project . Dr. Wilson breaks it down using three simple charts which I have consolidated to one.

Dr. Perry Wilson starts off making an overall point about the rising cost of healthcare from 1996 to 2013 and stating; "after accounting for inflation, healthcare expenditures increased $933.5 billion from 1996 to 2013."

Going on: "Healthcare expenditures in the US being high and rising rapidly is nothing new, but the study appearing in the Journal of the American Medical Association identifies the exact components of healthcare that are driving those soaring costs. The data from this study suggests traditional economic forces break down in the US healthcare market.

Different chronic diseases have different patterns of price increases. The biggest increase was seen in diabetes care, as you can see here, driven largely by the rising costs of pharmaceuticals."

The Chart breakdowns reveal the various impacts of healthcare costs moving from left to right and then downward:

• 50% of the increase in healthcare costs was simply due to higher prices.

• Inpatient care or Service Utilization (purple) went down from 1996 – 2013 as outpatient treatment increased; however, the price of the remaining inpatient care went up much more – increasing overall inpatient care spending by around $250 billion.

• Different Chronic Diseases have different patterns of price increases. The biggest increase was seen in diabetes care and driven largely by the rising prices of pharmaceuticals.

The takeaway drawn by Dr Perry Wilson: "Regardless of the disease, it is clear, the price of what we're buying – whether a drug, an ED visit, or a hospital stay – not the amount of what we're buying is the major driver of cost increases . Efforts to reduce the consumption of healthcare may not bend the cost curve as much as efforts to reduce its price."

You can not make an argument about the regulation of costs "not" being one of the dynamic components of a healthcare plan given the continuous unhindered industry driven rising cost of healthcare. Yet, every healthcare plan I have read fails to mention cost regulation specifically, provide remedy for it, and many assume a natural occurrence of control.

Tags: run75441 Comments (9) Digg Facebook Twitter Comments (9)

Longtooth , November 26, 2017 12:59 am

Run thanks for this, but in my opinion you're avoiding the central problem , though you briefly touched upon it without being more explicit:

"This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and restricted manufacturing throughput. "

The market can't be controlled by the pharmaceutical companies unless the government lets them. So this is a government sourced and caused problem unless you believe laissez-fair is the gov'ts job to promote and endorse.

You can't blame the pharmaceutical companies for doing precisely what the gov't lets them do by law.. the pharmaceuticals company's owners are in this to be philanthropic are they?

What you are essentially not coming to grips with is that our government is not designed to be democratic but designed by it's concept to be a system to ingratiate those who pay the most to keep the gov't in power which is to say those that represent them are paid to do their bidding in other words a gov't controlled by the sources of wealth to maintain it. if it were anywhere near a democratic system, how could 1% control it?

Longtooth , November 26, 2017 1:08 am

Run, sorry I forgot that there's never been a democratic system from the Spartan through the Athenian to the present that hasn't been controlled by the wealth. There have only been moments brought about by extreme deprivation that have had to deal with that deprivation to avoid revolution.

When we want to fix U.S. healthcare costs and quality we know how to do it, but you have to fix the system of government we employ to do it. Address the source of the problem rather than effects of it.

Longtooth , November 26, 2017 1:36 am

Run, let me only add that I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system at the same time. That is the actual dilemma since they are mutually exclusive.

If you think about how to "comprise" one with the other then you have to decide how such compromise is made and sustained (sustained being key word) and I can't see or find any evidence in U.S. history that suggests such compromise has ever worked to provide for the greater good on a sustained basis.

Perhaps its not even possible among human systems of civilized government .. but then why the charade as if it is? If the public wants to improve the healthcare system then why does it elect Presidents and representatives who don't want to improve it? If the public want's to improve the healthcare system why do Supreme Court interpret the Constitutional "law" to prevent it? Or if the 200+ year old constitutional law is so outdated as to be irrelevant than why doesn't the pubic demand to change it?

Or does the pubic want it's cake and eat it too? The public may be confused (I'm sure of this in fact) because they want simultaneously mutually exclusive conditions.

Denis Drew , November 26, 2017 9:29 am

Run, great major post.

Long, " I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system "

No? Look at continental Europe -- look at across the board labor union density -- look at sector-wide labor agreements. Come to think look at our northern neighbor.

Mostly all other problems from health care to student debt to everything are just symptomatic of the same economic/political-union free pathology. Bernie and Eliz don't spend a lot of time looking abroad either -- or even looking at 1973 stateside.

Come a Dem Congress I think the best idea is:
Why Not Hold Union Representation Elections on a Regular Schedule?
Published November 1st, 2017 – Andrew Strom

https://onlabor.org/why-not-hold-union-representation-elections-on-a-regular-schedule/

This can be sold as taking a page from Repub govs (e.g., Walker) who force government employee unions to re-certify every year -- with majority of union members, not just those who vote, required to retain.

I'm playing with the idea of proposing (via spam mail*) re-certification for every union in the country every year -- oh, of course, that would include certification elections for every nonunion workplace: that's the Trojan Horse .

We really want to certify/recertify every three or five years (three at first while we are trying to build density -- maybe five later on). Once we organize enough we can write the rules any way we want. By proposing re-certification every year (from my spider hole in Chicago) maybe I can get union members dander up and thereby at least wake them up to the issue. Cab driver political drama.

(* I have about 2000 email addresses, journalists, union, academic, politicians -- in WA, OR, CA, NV -- that I like to hit with new ideas.)

run75441 , November 26, 2017 11:40 am

Denis:

You may want to look at this again. A portion of it was blocked due to an error in linking to an article on Pharma costs which was kind of important. I have another article coming out which will discuss Pharmaceutical companies pulling advertising from medical news sites and mags if they are critical of pharma. As I read each of these articles, I could see a similar thread in them.

in 2015, AARP broke ties with MetLife over LTC insurance which MetLife discontinued in 2011 (no new applications). No big deal except AARP never told its membership of the AARP sponsored insurance break with MetLife. AARP now has a new LTC insurer New York Life announced as of 2015 and no letter to its members holding MetLife policies. Those who had AARP sponsored MetLife are now left with MetLife who is requesting a 21.75% increase just for cost over 3 years in addition to the normal inflation factor which was ~10% for 2018. AARP refers all inquiries to MetLife even though documents from MetLife still has AARP logos on it. Another interesting post of companies and Organizations screwing people.

Longtooth , November 26, 2017 5:48 pm

Dennis,

FWIW I come from a long line of union activists, members, and in one case a major union leader in the western U.S. and California in particular -- Building & Construction Trades Council.

I've been and remain a hugely strong union supporter. However my uncle (the Western US major union leader) was a realist and well understood the nature of economics viz-a-viz unions and capital owners.

In a series of discussions while I resided with he and his wife during one summer college break, he made me understand those trade-offs, and what drove them. At the time the college educated workforce in the US was 10% (4 year or better degree). He said a major factor in union's was the level of the college educated workforce and he said in 1966, that if the rate of college degree growth reached the then unprecedented rate of ~ 0.5%/year than in a few decades 1/3rd of the workforce would have college degrees -- the upshot of which is that they would very unlikely be persuaded to join unions or create new ones. His prognosis in 1966 turns out to be pretty close to reality even though he had little historic information to go on., .. he was not a pie in sky type, but a practical and major proponent of the general working class an working poor.

He also told me in 1966 that if unions demanded too much of the capital owners profits, they would resort to capital invested in automated methods -- his primary example of which was the hift to lath & plaster skilled union members to wall board which required no skill per-se and that forced union wages for interior "plasterers" down as lower skill and more efficient "sheetrock" hangers too over.

He cited other examples of automation replacing skilled union labor and without elaborating it was an eye-opener for me to see that unions were on their way down He not only knew the economics of building and construction business and labor, but of mining and manufacturing.

This was all long before Reagan's anti-unionism push (which in reality was Reagan using what was already well underway as a means of pumping up is conservative credentials).

My uncle's wisest advice was that if unions demanded more than capital owners were able to profit, they would simply use their capital in other enterprises where profits were greater -- this included not only investing in automated methods in mfg'ing and the building and construction trades (remember "sheetrock") , but in foreign low wage labor regions where especially mfg'ed goods could be produced at lower costs IF(the big IF in 1966) transportation and import duties made it more profitable to do so. He cited Mexico as the primary source of low transport cost low wage labor at the time, and at that time import duties from the few mfg'ed goods produced in Mexio were excessive which was the only reason mfg'ing hadn't shifted to use Mexican labor in Mexico for production and also why mfg'ing was investing more and more capital in automation. BUT, he said sooner or later it would become clear that capital owners would push to chane US import policies from Mexican roduced goods and the this would reduce mfg'ing's need for U.S. labor, thus Union's would have far less leverage to take a share of capital profits.

So he was a few decades off in his estimates, but he was right in 1966.. My uncle was among those in the U.S. union leaders who all understood all this very well what they said in public was different that what they saw occurring and would continue to occur they just didn't know then the rate of occurrence -- the computer age hadn't started . semi-conductors were being invented and barely developed for example. China's opening up hadn't occurred yet either. Clinton's NAFTA was still far in the future.

Through al the years since 1966 I've watched the progression of what my Uncle told me during our discussions in the summer of 1966. take place, for precisely the reasons he (and other major union leaders) knew they would.

In hindsight what fails in the U.S. relative to Europe is Germany's constitutional protections of labor unions. which by osmosis transfers to the other major European nations just as U.S. union wages and benefits transferred by the same osmosis to non-union wages and benefits rising to keep pace.

Keep up the good fight, Dennis, but you're forgetting about the economic realities in the US and it's individualism worship and constitution that protects it. .

JackD , November 26, 2017 9:22 pm

Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge. With Democrats in charge, it's tough enough. Witness the ACA's development and the impact of the blue dogs.

JimH , November 27, 2017 10:28 am

JackD wrote "Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge."

I could not agree with you more.

The Republicans' implementation of Medicare Part D which forbids negotiation of drug prices was asinine. Where was their concern for the national deficits and debt?

On heath care President Obama was negotiating with the duplicitous. His opposition had only one concern, their oath to Grover Norquist.

Daniel Becker , November 27, 2017 5:22 pm

It's not just that pharma has some say on what gets published, but in the health literature world, the trend was to only publish positive results.

As you can imagine, this has left a major void in truly understanding what happens in the body when a treatment is applied. There is a push to change this. Additionally, there is the push toward the idea of "numbers to treat". That is, how many have to receive the treatment to create one positive results. Outcomes can look a lot more different when looking at numbers to treat.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 29, 2017] The Best Health Care You Can Afford by marknesop

Notable quotes:
"... "No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick ..."
"... "Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems." ..."
"... The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments ..."
"... "The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity. ..."
"... Interesting article. Looks like the rot in the US is terminal. ..."
"... This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. ..."
"... Privatisation has meant profits for businesses, poor services to vulnerable groups. ..."
Nov 27, 2017 | marknesop.wordpress.com

"The art of medicine consists of amusing the patient while nature cures the disease."

"No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick

Cory Doctorow; Homeland

"Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems."

Karen Sullivan; The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments

No, I haven't abandoned Uncle Volodya, or shifted my focus to American administration; what follows is a guest post on the American healthcare system, by our friend UCG. As I've mentioned before – on the occasion of his previous guest post, in fact – he is an ethnic Russian living in the Golden State.

As an American in America, naturally his immediate concern is going to be healthcare in America; but there are lessons within for everyone. Don't get me wrong – doctors have done a tremendous amount of good, and medical researchers and many others from the world of medicine have made tremendous advances to which many of us owe their lives. Sadly, though, once a field goes commercial, the main focus of attention eventually becomes profit, and there are few endeavors in which the customer base will be so desperate. While there are obvious benefits to 'socialized medicine' such as Canada enjoys and American politicians scorn as 'Commie' – enough to earn the admiration of many – it results in such a backlog for major operations that those who don't like their chances of dying first, and have the money or can somehow get it, often flee to America, where you can get a good standard of medical care without running out of time waiting for it.

Without further ado, take it away, UCG!!

Healthcare in America

This article is my opinion. My hope is that others will do their own research on America's Healthcare Industry, because this is an issue that needs to be addressed, and for this article to be a mere starting point in this research. The reason for my citations is so that you, the reader, can verify them. Once again, this is my opinion. I write this in the first paragraph, so that I can avoid stating "in my opinion" before every sentence.

Let's start with Owen Davis who was charged $14,018 for going to a hospital because he sliced his hand, and they fixed it . A study published by Johns Hopkins showed that for $100 of ER treatment, some hospitals were charging patients up to $1,260 . A redditor claimed that :

I tore my ab wall a month ago and didn't think much of it until my pain kept worsening. I went to an immediate care facility to rule out a hernia (I had all the symptoms) and they told me to get to ER ASAP. I go to the ER and they give me a CT scan and one x-ray and say it's not a hernia and let me go. Fast forward to today and I got a bill for $9,200 and $3,900 of it is out of pocket. $9,200 for two tests???? No pain meds were administered; it was literally those two tests. What should I do to contest it? I will be calling tomorrow to demand an itemized bill, but is there anything else I should do in the meantime?

All of these took me a few minutes on Google to find, and another few minutes to post. The reason I chose that reddit, is because one of the readers offered an ingenious solution: Next time you hurt yourself – book a return ticket to NZ – go to accident and emergency, say you're a tourist and you hurt yourself surfing, pay nothing – fly home and pocket $8,000 in spare change. If that was me, I'd spend at least $2,000 on tourism in New Zealand. You guys have that system, so you clearly deserve the money! Anyone interested in a startup?

But I am not done with examples just yet. Shana Sweney described her experience in the emergency room : I delivered in 15 minutes. During that time, the anesthesiologist put a heart rate monitor on my finger and played on his phone. My bill for his services was $3,000. $200/minute. I talked to the insurance company about it – and since I ran my company's benefit plans, I got a little further than most people, but ultimately, that was what their contract with the hospital said so that's what they had to pay. Regardless of if he worked 15 minutes or 3 hours. Similarly, my twins were born prematurely and ended up in the NICU for 2 weeks. While the NICU was in-network for my insurance, for some mysterious reason, the neonatologists that attended the NICU were out of network. I think that bill was $16k and they stopped by to see each kid for an average of about 30 min/day.

Almost done with the examples, just please bear with me. How would you like a hospital billing you $83,046 for treating a scorpion sting , if a Mexican ER might have treated you for the same type of sting for $200? Perhaps being charged $546 for six liters of saltwater is more to your liking? $1,420 for two hours of babysitting ? $55,000 for an appendicitis operation ? $144,000 to deliver a perfectly healthy, albeit quite impatient baby? According to my interpretation of the sources linked, all of these actually happened. I encourage you to do your own research.

The World's Biggest Legalized Corruption (IMHO)

$984.157 billion. That's $984,157,000,000. That is how much money I believe the United States wastes on Healthcare. Not spends; wastes. As in money down the drain. The astute reader figured out that equates to five percent of America's 2016 GDP . Said reader is absolutely correct. How did I estimate such a gargantuan amount? According to the OECD data , in 2013 the United States spent 16.4 percent of its GDP on Healthcare; the two next biggest spenders, Switzerland and the Netherlands spent 11.1 percent. Even if one was to give the United States the benefit of doubt, and claim that the United States healthcare is just as efficient as that of Switzerland or the Netherlands – which is most likely not true according to an article from Business Insider , but even if it was – that meant that the United States wastes 5.3% of its GDP on healthcare. Wastes. I just want to make sure that the amount of this alleged legalized corruption, which will most likely reach a trillion dollars by 2020, is noted.

Let me place those funds into perspective: it's almost as much as the amount that the rest of the World spends on the military, combined . The SCO member states, including China, Russia, India, and Pakistan spent roughly $360 billion on the military . The wasted amount is equivalent to the GDP of Indonesia, and greater than the GDP of Turkey or Switzerland . In 2016, the US Federal Government spent $362 billion, or 36.8% of the wasted amount, to run all Federal Programs , including the Department of Education and NASA, with the exception of Social Security, Medicare/Medicaid, Veteran's Affairs, the military, and net interest on the US debt. All other Federal Programs were covered with the $362 billion. The US Federal Debt stands at $20.4 trillion , meaning that the debt can be paid off in 30 years, merely if the Healthcare Waste is eliminated.

But why stop there? The US Housing Crisis started partly because loans were allowed to be taken out without the 20% down payment. Could this funding, if applied directly to the housing market, stop the 2008 Great Recession? Absolutely, and all the Federal Government had to do was to gear these funds towards down payment on subprime mortgage loans to meet the 20 percent barrier. I can go on and on about what can be accomplished, like making collegiate attendance free, or at least very inexpensive, or drastically improving the quality of education, paying off the national debt, reinvesting into the economy, reinvigorating the rural sector, and so on, and so forth. A trillion dollars is a lot of money.

Lobbyists, the Media and the Waste

Any guess how much was spent on lobbying by the Healthcare, Insurance, Hospitals, Health Professionals, and HMOs? How about 10.5 billion dollars? I knew that was your guess! That's a lot of money, and that does not include "speaking fees", or when a politician who constantly made calls beneficial to the Healthcare Lobby gets $150,000 to speak in front of an audience after they retire from politics. Obama made a speech in front of Wall Street, netting $400,000 . And by pure coincidence, only one Wall Street Broker was jailed as a result of the scandal. That $10.5 billion is just a tip of the iceberg, because "speaking fees" are notoriously hard to track, and not included in said amount.

Obama genuinely tried to reform US Healthcare to the Swiss Model. He was going to let Wall Street slide, he was going to let Neocons conduct foreign policy, just please, let him have healthcare! First, the lobbyists laughed in his face. Second, they utilized the Blue Dog Coalition to block Obama's attempt at Healthcare Reform, until it was phenomenally nerfed, and we have the disaster that we have today. As a result, Obama's Legacy, Obamacare is having major issues, including the rise of racism.

Obamacare helped the poor, (mostly minorities,) at the expense of the middle class, (mostly whites,) thus transferring funding from whites to minorities. While the intent was not racial, it is being called out as racial by the mainstream media . This probably suits the lobbyists, because if the debate is about racism, one cannot have a genuine discussion about Healthcare Reform.

Racism strikes both ways. Samantha Bee came out with a "fuck you white people" message right after the election. Jon Stewart, without whom she probably wouldn't have her own show, pointed out that it was simply economics, like the healthcare insurance premium increase , that brought Donald Trump to power. Interestingly enough, James Carville made the same argument when Bill Clinton beat George Bush, but when Hillary Clinton lost, Carville was quick to blame Russia. These delusions on the Left are letting the Right mobilize stronger than ever before. And all of this takes away from the Healthcare Debate.

In an attempt to blame Trump's Election on white racism, rather than basic economics, numerous outlets simply fell flat. For instance, Eric Sasson writes : white men went 63 percent for Trump versus 31 percent for Clinton, and white women went 53-43 percent. Among college-educated whites, only 39 percent of men and 51 percent of women voted for Clinton What's more, these people hadn't suffered under Obama; they'd thrived. The kind of change Trump was espousing wasn't supposed to connect with this group.

Did this group thrive? The collegiate debt went from $600 billion to $1.4 trillion under Obama's Administration, while the health insurance increased from $13,000 to $18,000 per family . This is thriving? Was the author experimenting with medical marijuana when said article was written? Nevertheless, the parade of insanity continued, with Salon assuring us that it was blatant racism that gave us Trump . The Root, which also claimed that Russians attempted to hack election machines, pointed out that Russia exploited America's racism , and thus Trump won the election. Washington Post claimed that racism motivated white people more than authoritarianism . Comedian Bill Maher tried to sway the discussion back to economics, by pointing out that outrage over Pocahontas or Halloween should not stop the Democrats from working for the working man . Sadly, Maher and Stewart are in the minority, and instead of a Healthcare Debate, the US is now stuck in a debate over racism, which isn't even three-fifths as effective. Meanwhile the US continues to waste almost a trillion dollars on healthcare .

Who Benefits?

Let's start with the banks. Medical students graduate with an average of $416,216 in student debt . The average interest rate on said loan is seven percent. Roughly 20,055 students go through this program, per year . Presuming a twenty year loan, the banks are looking at about $7.185 billion in interest payments. It really is a small fraction of the cost. Prescription drug prices are another story. In 2014, Medicare spent $112 billion on medicine for the elderly . Oh la la! Cha-ching. I would not be surprised if at least half of that was wasted on drug price inflation. You know the health insurance companies? It's a great time to be one, since profits are booming – to the tune of $18 billion in projected revenue for 2017.

Of course the system itself is quite wasteful, with needless hours spent on paperwork, claim verification, contractual review, etc, etc, etc. Humana's revenue was $54.4 billion , Aetna's was $63.2 billion , Anthem's was $85 billion , Cigna's was $39.7 billion , and UnitedHealth's was $184.8 billion . Those are just the top five companies. None of them ia a mom-and-pop shop or small business store. Do any of these insurers support Obamacare? Even if they do, it is without much enthusiasm . They are leaving, and leaving quite quickly. Thirty-one percent of American counties will have just one healthcare insurer . Welcome to a monopoly that is artificially creating itself. And despite the waste, 28.2 million Americans remain uninsured . Mission accomplished!

Who else benefits? Those who hire illegal immigrants instead of American workers, since illegal immigrants cost the United States roughly $25 billion in Healthcare spending . Meanwhile those who hire them can avoid certain types of taxes and not have to cover their Healthcare; communism for the rich, capitalism for the rest of us. Of course that is just a rough estimate, since this spending is also quite hard to track.

The Future

The problem with changing Healthcare is that too many people have their hands in the proverbial pie. There is not a single lever of power that isn't affected by Healthcare, and most of the levers that are affected, benefit quite a bit. Insurance companies will fight to the death, because Universal Healthcare will be their death knell. Banks will defend it, because who doesn't want to make billions from student loans? Medical schools too – since it lets them charge higher and higher tuition. Pharmaceutical companies can use the increase in Healthcare expenditure to justify their own price hikes, even though a major reason for those price hikes is artificial patent based monopoly.

What is an artificial monopoly? In my opinion, it's when a patent is utilized to prevent competitors from manufacturing the same exact drug. In less than a decade, the price of Epi-Pen soared from $103.50 to $608.61. When asked the justify said increase, one of the reasons provided by the CEO was that the price went up because we were making investment; as I said, about $1 billion over the last decade that we invested in the product that we could reach physicians and educate legislatures. "Reaching" doctors and legislators; I wonder, how was said "education funding" spent? According to US News, a website that is extremely credible when it comes to internal decision making within the United States, drug companies have long courted doctors with gifts , from speaking and consulting fees to educational materials to food and drink. But while most doctors do not believe these gifts influence their decisions about which drugs to prescribe, a new study found the gifts actually can make a difference – something patient advocates have voiced concern about in the past. Do you feel educated? Would you feel more educated if I paid you a $150,000 consulting fee? What about $400,000? What? It's just consulting; no corruption here!

Everyone knows that this is going on. But there is not going to be change. Why not? The same reason that there was not change with Harvey Weinstein, until Taylor Swift came along. Remember how I said that almost everyone has their hands in the Healthcare Pie? It was not much different with Weinstein. Scott Rosenberg explained why it took so long for people to speak out against Harvey , and the reasons were numerous. First, Harvey gave many people their start in Hollywood, and treated all of his friends like royalty. That drastically increased their loyalty. Second, he ushered the Golden Age of the 1990s, with movies like Pulp Fiction, Shakespeare in Love, Clerks, Swingers, Scream, Good Will Hunting, English Patient, Life is Beautiful – the man could make phenomenal movies. Third, even if one was willing to go against his own friends, workers, mass media, and so on, there was no one to tell. There was no place to speak out. Fourth, some of the victims took hefty settlements.

That fourth reason enabled mass media to portray rape victims as gold diggers. Rape Culture is alive and well. In California, a Judge gave minimal sentencing to a convicted rapist , because he was afraid a harsher sentence would damage the rapist's mental psyche for life. Uh dude, from one Californian to another, he, uh, raped. His mental psyche is already damaged; for life. That's the kind of pressure that Rose McGowan had to deal with. She had a little kerfuffle with Amazon , and she thinks it was partially because of Harvey Weinstein. How many times had the word "socialism" been thrown around to describe Universal Healthcare? Switzerland has it – are they Socialist?

Enter Taylor Swift . In order to destroy allegations that women are filing sexual harassment claims as gold diggers, she sued her alleged sexual assaulter for a buck; one dollar. She won. Swift stated that the lawsuit was to serve as an example to other women who may resist publicly reliving similar outrageous and humiliating acts. On top of that, Weinstein was no longer as popular as he used to be, and an avenue to tell the story, an outlet was created. The additional prevalence of the internet caused the stories of Weinstein's sexual abuse to leak. Within a month, the giant fell.

Something similar is needed to change Healthcare in America. But until that comes along, racism will increase, the cost of Healthcare will rise, emergency room costs will most likely double every ten years, and the future remains bleak. As if that was not enough, more and more upper class Americans, (like yours truly,) are seeking treatment abroad. It cost me less money to lose five weeks of wages, spend three weeks partying in Eastern Europe, (Prague to be more specific,) after my two weeks of treatment, buy a roundtrip plane ticket, and stay in a five star, all-inclusive hotel, than the cost of the same treatment in the US. If anyone wants to utilize this as a startup – let me know!

Of course its effects on Healthcare will hurt, since it is a huge chunk of business that will be traveling across the Atlantic. But what can be done to stop it? One cannot stop Americans from traveling to other countries. One cannot force the poor to work for free. Perhaps this is the change that is needed to make those who benefit from the Healthcare Waste realize that this cannot continue. Perhaps not. What we do know, is that Obamacare insured the poor, at the expense of the middle class . And that is regarded as a failure in America.

Northern Star , November 27, 2017 at 3:12 pm
As for Obongo Care ??:

"In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives -- aka Obamacare's middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would.
****The new law instead cemented the industry's profit-extracting role in the larger health system -- and it still leaves millions without insurance."*** (THAT is the Achille's lower torso of the ACA)

https://www.healthcare-now.org/blog/single-payer-healthcare-vs-obamacare/

https://www.dailykos.com/stories/2016/2/11/1483523/-Single-Payer-Healthcare-vs-The-Affordable-Care-Act-A-Simple-Comparison

ucgsblog , November 28, 2017 at 3:58 pm
Exactly! That's why I stated that they're now oligapolizing the market, and will slowly start to increase their insurance rates and profits once again.
Northern Star , November 27, 2017 at 3:23 pm
"Prince Harry..Do you take this American mulatto negress -aka raghead untermensch-as your lawfully wedded royal wife?*
http://www.newsweek.com/prince-harrys-worst-moments-meghan-markle-rogue-723177
https://www.sbs.com.au/guide/sites/sbs.com.au.guide/files/styles/body_image/public/nazi.jpg?itok=q1oxMi44&mtime=1503879842

Ummm Advice to Meghan .make sure the honeymoon motorcade stays clear of tunnels in Paris
or elsewhere!!!

Northern Star , November 27, 2017 at 3:52 pm
Appurtenant to many of the issues raised in Mark's post:

http://www.wsws.org/en/articles/2017/11/27/pers-n27.html

(Socialist or not..the WSWS writers continue to state that which NEEDS to be hammered home)

"The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity.

Amazon is a prime example. Its supply lines and delivery systems could distribute goods across the world, bringing water, food, and medicine from each producer according to his or her ability, to each consumer according to his or her need.

The massively sophisticated computational power used by the technology companies to censor and blacklist political opposition could instead be used for logistical analysis to conduct rescue and rebuilding missions in disaster zones like Houston and Puerto Rico. Drones used in the battlefield could be scrapped and rebuilt to distribute supplies for building schools, museums, libraries, and theaters, and for making Internet service available at no cost for the entire world.

The ruling class and all of the institutions of the political establishment stand inexorably in the way of efforts to expropriate their wealth. What is required is to mobilize the working class in a political struggle against the state and the socio-economic system on which it is based, through the fight for socialism.
Eric London "

Particularly for American Stooges:

Patient Observer , November 27, 2017 at 5:17 pm
Advanced technology is helpful but not essential for a humane and just society. Its what we believe and feel that matters. FWIW, I like socialism on a national/international level and individual accountability on a personal level.
saskydisc , November 27, 2017 at 4:04 pm
While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico.
Patient Observer , November 27, 2017 at 5:12 pm
Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.
anon@gmail.com , November 27, 2017 at 6:02 pm
I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.
kirill , November 27, 2017 at 8:38 pm
Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

Jen , November 27, 2017 at 11:15 pm
Thanks very much UCG, for your article. Very interesting reading for us Australians as the Federal Government eventually wants to shove us kicking and screaming into a US-style privatised healthcare insurance model.

Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.

Fern , November 28, 2017 at 7:02 am
I was just about to post along the lines of "I don't know if Jen has experienced this in Australia but here in the UK ." so I'll finish the thought. In the UK, successive governments, not just Conservative ones, have been trying to dismantle the NHS and move us to the American system. It is pure ideology – no amount of the very abundant evidence of the inefficiencies of the US system, its waste etc makes any dint in the enthusiasm of those pressing for change.
ucgsblog , November 28, 2017 at 4:17 pm
Thank you Jen! My advice: don't let the Government cajole you into wasting your money on Corporate Greed. Share the article with your fellow Australians, if you must, but don't let our wasteful system be replicated. Interestingly enough, one of my friends, Lytburger, send me a meme right after Ukraine adopted America's Healthcare System, it said: "ISIS refused to take responsibility for Ukraine's Healthcare Reform!" I'd be happy to provide other data or answer questions about the Healthcare System here.

As for insurance, I'm not sure if Australia has the in-network and out-of-network rules. Does it? Whatever insurance you get, make sure that it has good coverage. If you own a home in the US, and you end up in a hospital's emergency room that's not covered by your insurance, the hospital can take your house under certain circumstances. Ironically, even the Government cannot. All of my real property is in various Trust Accounts, just in case, and I make sure that I have insurance where all major hospitals are in-network and that's the best I can do.

James lake , November 28, 2017 at 12:21 am
This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.

Which many people do not mind.

-Elderly care was also privatised as it's the most expensive

-care for the disabled also is a issue for local councils

-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.

And yet still more and more taxation is needed for the NHS!

The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.
Ryan Ward , November 28, 2017 at 3:40 am
With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 15, 2017] Alex Azar Can There Be Uglier Scenarios than the Revolving Door naked capitalism

Notable quotes:
"... By Lambert Strether ..."
"... So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy. ..."
"... In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real ..."
Nov 15, 2017 | www.nakedcapitalism.com

Alex Azar: Can There Be Uglier Scenarios than the Revolving Door? Posted on November 15, 2017 by Lambert Strether By Lambert Strether

Clearly, Alex Azar, nominated yesterday for the position of Secretary of Health and Human Services by the Trump Administration, exemplifies the case of the "revolving door," through which Flexians slither on their way to (or from) positions of public trust. Roy Poses ( cross-posted at NC ) wrote, when Azar was only Acting Secretary:

Last week we noted that Mr Trump famously promised to &#8220;drain the swamp&#8221; in Washington. Last week, despite his previous pledges to not appoint lobbyists to powerful positions, he appointed a lobbyist to be acting DHHS Secretary. This week he is apparently strongly considering Mr Alex Azar, a pharmaceutical executive to be permanent DHHS Secretary, even though the FDA, part of DHHS, has direct regulatory authority over the pharmaceutical industry, and many other DHHS policies strongly affect the pharmaceutical industry. (By the way, Mr Azar was also in charge of one lobbying effort.)

So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy.

Moreover, several serious legal cases involving bad behavior by his company, and multiple other instances of apparently unethical behavior occurred on Mr Azar&#8217;s watch at Eli Lilly. So the fox might be not the most reputable member of the species.

So you know the drill&#8230;. The revolving door is a species of conflict of interest . Worse, some experts have suggested that the revolving door is in fact corruption. As we noted here , the experts from the distinguished European anti-corruption group U4 wrote ,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy , especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism.

Poses is, of course, correct. (Personally, I've contained my aghastitude on Azar, because I remember quite well how Liz Fowler transitioned from Wellpoint to being Max Baucus's chief of staff when ObamaCare was being drafted to a job in Big Pharma , and I remember quite well the deal with Big Pharma Obama cut, which eliminated the public option , not that the public option was anything other than a decreasingly gaudy "progressive" bauble in the first place.)

In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real damage Azar could do is on the regulatory side.[1]

First, Democrat credentialism. Here is one effusive encomium on Azar. From USA Today, "Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency" :

"I am glad to hear that you have worked hard, and brought fair-minded legal analysis to the department," Democratic Sen. Max Baucus said at Azar's last confirmation hearing.

And:

Andy Slavitt, who ran the Affordable Care Act and the Centers for Medicare & Medicaid Services during the Obama administration, said he has reason to hope Azar would be a good secretary.

"He is familiar with the high quality of the HHS staff, has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor," Slavitt said.

So, if Democrats are saying Azar is "fair-minded" and "pragmatic" -- and heaven forfend that the word "corruption"[2] even be mentioned -- how do they oppose him, even he's viscerally opposed to everything Democrats supposedly stand for? (Democrats do this with judicial nominations, too.) Azar may be a fox, alright, but the chickens he's supposedly guarding are all clucking about how impeccable his qualifications are!

Second, let's briefly look at Azar's bio. Let me excerpt salient detail from USA Today :

1. Azar clerked for Supreme Court Justice Antonin Scalia .

2. Azar went to work for his mentor, Ken Starr , who was heading the independent counsel investigation into Bill and Hillary Clinton's Whitewater land deal.

3. Azar had a significant role in another major political controversy when the outcome of the 2000 presidential election hinged on a recount in Florida . Azar was on the Bush team of lawyers whose side ultimately prevailed [3]

For any Democrat with a memory, that bio provokes one of those "You shall know them by the trail of the dead" moments. And then there's this:

When Leavitt replaced Thompson in 2005 and Azar became his deputy, Leavitt delegated a lot of the rule-making process to Azar.

So, a liberal Democrat might classify Azar as a smooth-talking reactionary thug with a terrible record and the most vile mentors imaginable, and on top of it all, he's an effective bureaucratic fixer. What could the Trump Administration possibly see in such a person? Former (Republican) HHS Secretary Mike Leavitt explains:

"Understanding the administrative rule process in the circumstance we're in today could be extraordinarily important because a lot of the change in the health care system, given the fact that they've not succeeded legislatively, could come administratively."

We outlined the administration strategy on health care in "Trump Adminstration Doubles Down on Efforts to Crapify the Entire Health Care System (Unless You're Rich, of Course)" . There are three prongs:

1) Administratively, send ObamaCare into a death spiral by sabotaging it

2) Legislatively, gut Medicaid as part of the "tax refom" package in Congress

3) Through executive order, eliminate "essential health benefits" through "association health plans"

As a sidebar, it's interesting to see that although this do-list is strategically and ideologically coherent -- basically, your ability to access health care will be directly dependent on your ability to pay -- it's institutionally incoherent, a bizarre contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven single payer system. ( Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and new executive orders . We might compare ObamaCare to a child born with no immune system, that could only have survived within the liberal bubble within which it was created; in the real world, it's not surprising that it's succumbing to opportunistic infections.[2])

On #1, The administration has, despite its best efforts, not achieved a controlled flight into terrain with ObamaCare; enrollment is up. On #2, the administration and its Congressional allies are still dickering with tax reform. And on #3 . That looks looks like a job for Alex Azar, since both essential health benefits and association health plans are significantly affected by regulation.

So, yes, there are worse scenarios than the revolving door; it's what you leave behind you as the door revolves that matters. It would be lovely if there were a good old-fashioned confirmation battle over Azar, but, as I've pointed out, the Democrats have tied their own hands. Ideally, the Democrats would junk the Rube Goldberg device that is ObamaCare, rendering all of Azar's regulatory expertise null and void, but that doesn't seem likely, given that they seem to be doing everything possible to avoid serious discussion of policy in 2018 and 2020.

NOTES

[1] I'm leaving aside what will no doubt be the 2018 or even 2020 issue of drug prices, since for me that's subsumed under the issue of single payer. If we look only at Azar's history in business, real price decreases seem unlikely. Business Insider :

Over the 10-year period when Azar was at Lilly, the price of insulin notched a three-fold increase. It wasn't just Lilly's insulin product, called Humalog. The price of a rival made by Novo Nordisk has also climbed, with the two rising in such lockstep that you can barely see both trend lines below.

The gains came despite the fact that the insulin, which as a medication has an almost-century-long history, hasn't really changed since it was first approved.

Nice business to be in, eh? Here's that chart:

It's almost like Lilly (Azar's firm) and Novo Nordisk are working together, isn't it?

[2] Anyhow, as of the 2016 Clinton campaign , the Democrat standard -- not that of Poses, nor mine -- is that if there's no quid pro quo, there's no corruption.

[3] And, curiously, "[HHS head Tommy] Thompson said HHS was in the eye of the storm after the 2001 terrorist attacks, and Azar had an important role in responding to the resulting public health challenges, as well as the subsequent anthrax attacks "

MedicalQuack , November 15, 2017 at 10:31 am

Oh please, stop quoting Andy Slavitt, the United Healthcare Ingenix algo man. That guy is the biggest crook that made his money early on with RX discounts with his company that he and Senator Warren's daughter, Amelia sold to United Healthcare. He's out there trying to do his own reputation restore routine. Go back to 2009 and read about the short paying of MDs by Ingenix, which is now Optum Insights, he was the CEO and remember it was just around 3 years ago or so he sat there quarterly with United CEO Hemsley at those quarterly meetings. Look him up, wants 40k to speak and he puts the perception out there he does this for free, not so.

diptherio , November 15, 2017 at 11:25 am

I think you're missing the context. Lambert is quoting him by way of showing that the sleazy establishment types are just fine with him. Thanks for the extra background on that particular swamp-dweller, though.

a different chris , November 15, 2017 at 2:01 pm

Not just the context, it's a quote in a quote. Does make me think Slavitt must be a real piece of work to send MQ so far off his rails

petal , November 15, 2017 at 12:52 pm

Alex Azar is a Dartmouth grad (Gov't & Economics '88) just like Jeff Immelt (Applied Math & Economics '78). So much damage to society from such a small department!

sgt_doom , November 15, 2017 at 1:21 pm

Nice one, petal !!!

Really, all I need to know about the Trumpster Administration:

From Rothschild to . . . .

https://en.wikipedia.org/wiki/Wilbur_Ross

Since 2014, Ross has been the vice-chairman of the board of Bank of Cyprus PCL, the largest bank in Cyprus.

He served under U.S. President Bill Clinton on the board of the U.S.-Russia Investment Fund. Later, under New York City Mayor Rudy Giuliani, Ross served as the Mayor's privatization advisor.

Jen , November 15, 2017 at 7:56 pm

Or from a "small liberal arts college" (which is a university in all but name, because alumni).

Tim Geitner ('82 – Goverment)
Hank Paulson ('68 – English)

jo6pac , November 15, 2017 at 2:13 pm

Well it's never ending game in the beltway and we serfs aren't in it.

https://consortiumnews.com/2017/11/15/trump-adds-to-washingtons-swamp/

Alfred , November 15, 2017 at 2:53 pm

I don't believe that the President's "swamp" ever consisted of crooked officials, lobbyists, and cronies I think it has always consisted of those regulators who tried sincerely to defend public interests.

It was in the sticky work of those good bureaucrats that the projects of capitalists and speculators bogged down. It is against their efforts that the pickup-driving cohort of Trump_vs_deep_state (with their Gadsden flag decals) relentlessly rails.

Trump has made much progress in draining the regulatory swamp (if indeed that is the right way to identify it), and no doubt will make considerably more as time wears on, leaving America high and dry. The kind of prevaricator Trump is may simply be the one who fails to define his terms.

Henry Moon Pie , November 15, 2017 at 4:13 pm

I think we've moved past the revolving door. We hear members of the United States Senate publicly voice their concerns about what will happen if they fail to do their employers' bidding (and I'm not talking about "the public" here). In the bureaucracy, political appointees keep accruing more and more power even as they make it clearer and clearer that they work for "the donors" and not the people. Nowhere is this more true than the locus through which passes most of the money: the Pentagon. The fact that these beribboned heroes are, in fact, setting war policy on their own makes the knowledge that they serve Raytheon and Exxon rather than Americans very, very troubling.

I suspect Azar's perception is that he is just moving from one post to another within the same company.

Watt4Bob , November 15, 2017 at 5:28 pm

Perfect cartoon over at Truthout

I'm amazed there is enough private security available on this planet to keep these guys safe.

Larry , November 15, 2017 at 8:01 pm

Big pharma indeed has so much defense from the supposed left. It combines their faith in technological progress, elite institutions, and tugs on the heart strings with technology that can save people from a fate of ill health or premature death. Of course, the aspect of the laws being written to line the pockets of corrupt executives is glossed over. While drug prices and medical costs spiral ever higher, our overall longevity and national health in the US declines. That speaks volumes about what Democrats really care about.

[Oct 27, 2017] Prime case of crapification in medicine is that many doctors bowled over by the drug companies

Notable quotes:
"... One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session). ..."
"... I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight. ..."
"... Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy ..."
"... Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes." ..."
"... Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. ..."
"... ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines: ..."
"... Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea. ..."
"... Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system. ..."
"... EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies" ..."
"... I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child ..."
"... And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on. ..."
"... And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's ..."
"... I think, what this article alludes to is that medicine is complex and not easily algorithmic ..."
"... The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency. ..."
"... My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience. ..."
"... Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized. ..."
"... My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care ..."
Oct 27, 2017 | www.nakedcapitalism.com

el_tel , October 27, 2017 at 7:24 am

Interesting article and a couple of clarifications:

Psychologists have studied the accuracy of risk assessments made by statistical predictors and by clinicians, but they have not done similar studies of the accuracy of evaluations of patient preferences over health outcomes.

True but health economists have done so . And they got so scared by the results that some (Dolan) left the field to do something else. This particular example is that whilst the general population reckons "extreme pain" to be worse than "extreme depression/anxiety", those members of the population who'd experienced them both put them the other way round. Which has profound implications for the UK values assigned to health outcomes. Of course other countries might do things in different ways and this is NOT some veiled attack on what the US might do if single payer gets onto the playing field. It's merely adding to the warning in the paper about how to do it. Which leads to a second warning I'd make – averages. They conceal a lot.

Mental health is the archetypal example and, again, maybe the paper is right that something like maximin is warranted, given that "living by averages" means some groups automatically lose out. Just some thoughts, which hopefully are constructive this time round and expand on points made.

PlutoniumKun , October 27, 2017 at 8:19 am

One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session).

I talked much later to a family member who is a specialist in prescribing practice who said that this was by far the most common misdiagnosis/treatment and as late as the 1990's in the UK (where he did research on the subject), he found that 25% of GP's (family doctors) were not identifying asthma correctly. Very often, pharmacists are the only gatekeepers to identify bad prescribing practices.

I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight.

JTMcPhee , October 27, 2017 at 10:04 am

I'd ask what the author assumes is the best model for doctor-patient interaction, what "patient care" means. To me it should be two or maybe more (including nurses and family members and other caregivers) people, ones with more knowledge of physiology and systems, others with more knowledge and experience of whatever the "presenting condition" happens to be, interacting to increase longevity, reduce pain, repair damaged structures, correct physiological malfunctions and problems with homeostatic functions and so forth, to maximize function, independence and comfort -- an incomplete definition of a very complex notion.

Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy

Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes."

But there's almost an infinite number of ways humans can get injured, sickened and die. Human physiology is vastly complex. The interaction pathways are likewise near infinite. Medicine is an art of observation compounded over time, and a lot of the knowledge base (I personally hate that term) is just wrong, from a wide variety of causes including bias, sample size, things like referred pain, atypical "presentations," "normal variation" and so forth. When what to me is a semi-mystical interaction between practitioner and person works well, it is a thing of beauty and kindness. As with anything human-created and -mediated, too often the result is far worse -- most of us can insert one or more anecdotes here, on either extreme.

Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. It's a "whole new way of doing business:"

ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines:

Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea.

Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system.

EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies"

I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child when the family doctor, a partisan of allergies as the most common source of disease, and who patch-tested me and my sisters unmercifully, supposedly told my mom that my broken right forearm was the result of an allergy. And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on.

These observations only touch on an enormously complex and painfully meaningful subject. Seems to me that the best "we" patients and patients-to-be can expect is that we connect with clinicians that still start from "Do no harm" and aspire to better the lives of we who seek and depend on their expertise -- a notably, and inevitably, ever smaller fraction of the available "knowledge base." And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's

el_tel , October 27, 2017 at 10:15 am

Yeah I agree entirely . But more holistic approaches (judging medicine by overall quality of life) get into areas that have got a little Shall we say Controversial So I'm keeping my comments focused to stay within site guidelines.

cojo , October 27, 2017 at 12:08 pm

There are two reasons why patient care adhering to guidelines may differ from the care that clinicians provide:
Guideline developers may differ from clinicians in their ability to predict how decisions affect patient outcomes; or
Guideline developers and clinicians may differ in how they evaluate patient outcomes.

I think, what this article alludes to is that medicine is complex and not easily algorithmic. The concerns in medical decision making as noted by Yves and others is that if your data/knowledge you base your treatment choices on is outdated, or flat out wrong, you will be doing your patient's a disservice at best and harm at worse. In these situations evidence based medicine should be used as a guide. Where evidence based medicine runs into trouble, is two fold. One, when the guidelines are based on flawed evidence/data, and two, when they are no longer used as a guide, but as the law.

So in that case you may statistically help the population at large, based on the data at hand, but at the cost of doing preventable harm to a large cohort that could have been picked up by rational clinical decision making. This is where the "Art of Medicine" should theoretically be superior. The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency.

My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience.

With experience, the guidelines should still be understood but there is more flexibility to stray from the guidelines for individual patients based on patient preference and physician experience.

For those in the late stages of their careers, it is again important to understand and try to follow the guidelines so as to not become outdated in your practice knowledge.

At all three stages, one must understand the rational and methodology of the guidelines figure out which guidelines are to be used for most cases and which guidelines are just that, a guide.

Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized.

Jason , October 27, 2017 at 12:14 pm

I am a practicing internal medicine hospitalist in a major US city. While in the past, there were large delays in physicians taking evidence-based practice and turning it into new habit and too much unwanted variation in clinical practice -- I feel like in the US, the pendulum is swinging too far the other way -- and in unintelligent ways, forcing clinicians into care protocols without regard for individual circumstance. Now there are clinical care guidelines from Medicare, the American Heart Association, the CDC, and others around major disease states (like stroke, heart failure, sepsis) that hospitals must follow for reimbursement -- yet the guidelines do not keep pace with current peer-reviewed evidence.

My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care (sepsis guidelines now are a good example of this). Often these expectations are negotiated by bureaucrats, not clinicians. The healthcare industry needs a better way of giving physicians real-time feedback about their clinical practice habits in relation to their peers -- - and having some common-sense expectations around unwanted variations in practice.

financial matters , October 27, 2017 at 12:50 pm

Hopefully you can get yourself on some committees dealing with these issues. Very important to have physician input.

Economics is definitely important, not only for improving the hospitals bottom line but for making medicine economically responsible generally.

Single payer, I think would be great but we still need to watch what we are paying for. No need for pharmaceutical companies to make outrageous profits.

One interesting area now is that many very expensive tests are becoming available for cancer testing. These need to be ordered responsibly and that takes physician, social and admin input. And at a deeper level needs to examine why the tests, drugs etc are so expensive.

el_tel , October 27, 2017 at 1:01 pm

Tranylcypromine – first generation antidepressant and still the gold standard for effectiveness (the "cheese effect" side effect has been overblown as numerous studies have more recently shown – I'm on it and can confirm this) costs the NHS over £1000 per month for me. It's been off patent for 50 years. However there is a monopoly supplier (price gouger). Why don't generic suppliers move in? Because the market is too small. Two generations of doctors have been taught that this class (MAOIs) are akin to leech therapy. Thus the assumption is that most people on them will be old and will die off. Scandalous, as any psychiatrist worth their salt will tell you (never mind the health economist like me).

el_tel , October 27, 2017 at 1:36 pm

Prime case of cr*pification in medicine if you ask me. Doctors bowled over by the drug companies selling SSRIs/SNRIs which let's not forget don't even work as the pharmacology says they should – they should show benefits at day 4/5 like MAOIs if their original pharmacological justification is paid attention to. Now does that mean they don't work? No I'm not saying that. But their method of action is clearly odd and not in line with the original pharmacological data and models.

Health economics 102 is derived demand – patients rely on doctors to enunciate their demand function. But when doctors have effectively undergone the medical equivalent of regulatory capture then Houston we have a problem.

financial matters , October 27, 2017 at 1:54 pm

Yes indeed. These pharmacologic profits can be perniciously spread around. It can be difficult to find a true patient advocate.

el_tel , October 27, 2017 at 2:17 pm

Thanks for the reply. The problem here is that patient advocacy requires systemic change: change in the medical curriculum along with a concerted effort to tell GPs about the new data on "old" drugs And they are already overburdened with stuff "coming at them from on high".

Plus even if (say) they learn the real data concerning MAOIs they still can't prescribe them straight off A psychiatrist must initiate it (then GP can carry on) And mental health services are close to breaking point. My local service is at critical levels. Austerity yet again .

Bill , October 27, 2017 at 1:48 pm

I was going to a physical therapist practice for spasticity and weakness and pain related to a pretty radical cervical laminectomy and progressive spine problems. I was a Medicare patient and they insisted on using the guidelines for rehabilitation after operation, even though my operation took place 12 years earlier. This consisted of exercises which only made my spasticity worse and aggravated my arthritis. What I needed was to have my chest and arms worked on to counteract the contraction of muscles caused by spasticity, which the therapist knew how to do. But she refused and told me that If I did not do the exercises, she would no longer treat me as I was violating the "guidelines", which did not apply to my circumstance. There was apparently nothing to allow treatment for chronic problems (except opiods, which I refused).

el_tel , October 27, 2017 at 2:00 pm

Sorry to hear that. I had reason to look at the UK guidelines on a range of conditions (from NICE). I was actually pleasantly surprised: although they do in many cases follow "stepped care" functions from medicine, there were a surprising number of "get outs" regarding if the patient cannot tolerate /has good reason to reject the official guidance. Patient preferences have begun to get recognised in the UK.

Of course whether austerity allows the doctors to *afford* differences is another sad story .

Bill , October 27, 2017 at 2:59 pm

I guess that what I need now is what amounts to palliative care (non-pharmaceutical). I find now that I have discovered high-CBD hemp (Otto II strain) which I can grow myself, I can actually slow down the progressive effects of my condition. Ironically, though I qualify for the medical marijuana card, I can't afford to buy from the dispensaries, and they mainly offer high THC strains anyway. I am lucky to have found a way to treat myself!

[Oct 25, 2017] Overtreatment in the United States Health Care System

American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
Over-treatment involves actual procedures performed on a patient, often surgically. Unnecessary cardiac stents is one example and is a real epidemic due to excessive green and pervert incentives.
Notable quotes:
"... By Lambert Strether of Corrente. ..."
"... Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments. ..."
"... The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast. ..."
"... It's clear that one ..."
Oct 25, 2017 | www.nakedcapitalism.com

Posted on October 24, 2017 by Lambert Strether By Lambert Strether of Corrente.

Over the past, oh, decade or so I've been so consumed with the battle to get everybody into the heatlh care system -- "Everybody in, nobody out," as Quentin Young puts it -- that I haven't put much energy into thinking about the heatlh care itself. After all, just because a house is energy inefficient doesn't mean that it's OK to leave people out in the cold. Now that single payer is no longer "never, ever," but a program that could actually be achieved with (an enormous) level of effort, KHN's new series, "Treatment Overkill," which starts with Liz Szabo's "So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills," provides me with a change to broaden my scope a bit, with a survey post like this one.

So I'm going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of overtreatment? Spoilers: Yes, and it's complicated.

Confession time: I'm the sort of person who doesn't get the idea of deductibles at all; I can't understand why anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear the health care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia to remove a wisdom tooth; or my nightmare of "end of life care" hooked up to a machine in a nursing home in a room with a television I can't turn off.

Overtreatment Is Real Problem

Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys. I'll look at anecdotes first.

"Anecdotes" isn't really a fair word, though; most of the stories are more about entire vertical markets (for example, stents, as we shall see). Szabo starts out with this example:

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

"In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 -- six years before her diagnosis -- showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology , which writes medical guidelines, endorsed the shorter course.

In 2013 , the society went further and specifically told doctors not to begin radiation on women like Dennison -- who was over 50, with a small cancer that hadn't spread -- without considering the shorter therapy.

"It's disturbing to think that I might have been overtreated," Dennison said. "I would like to make sure that other women and men know this is an option."

(Note, sadly, that Dennison immediately puts the onus on the consumer patient to be informed; an obvious tax on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic solution she vaguely hints at with "would like to make sure." This impulse is a topic for another post.)

Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing "bed rest" for heart attack patients as "a form of medieval torture" as well):

[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women's Hospital in Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind of thing happened daily.

Here is a third, and egregious example, from Health Beat :

Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report..

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.

(It may seem that I'm stacking the deck on causality here, but I'm really not, although it would be foolish to deny that such cases exist.)

Note again that these examples all involve treatment : Radiation treatment, a pacemaker, and stents. We're not talking about ordering a few two many tests. ( The American Family Physican supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.

"Overtreatment in the United States," by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures.

Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear induced for no reason. And if one out of every ten treatments is unncessary, that's rather a lot of people going to Pain City because their number came up, and not for any medical reason. Those odds aren't quite as bad as Russian roulette, but they'e in the ballpark! I haven't (yet) been able to find figures on the costs of overtreatment, but there have been studies done on the costs of unnecessay care. Health Affairs :

Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health care spending. Even the lower estimate, from the Institute of Medicine , amounts to nearly $300 billion a year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11 percent of stents are delivered to " inappropriate patients ." At some hospitals, that rate is closer to 20 percent.

(Note that the figure of 11% unnecessary stents jibes well with Lyu's figure of 11.1% of all procedures being unnecessary.)

I'm sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may well be new to NC readers -- especially those who received treatments that they retrospectively, or just now, understood to be unnecessary.

The Causes of Overtreatment

It's clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al. :

The top three cited reasons for overtreatment were "fear of malpractice" (84.7%), "patient pressure/request" (59.0%), and "difficulty accessing prior medical records" (38.2%) Seventy-one percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them. The interpolated median response for the percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of experience (OR 1.89 (1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely to believe that physicians perform unnecessary procedures when they profit from them Respondents' compensation method and hospital characteristics were not associated with differences in perceptions on the profit motive associated with unnecessary care.

So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the sole driver (see "DICE: Nonclinical Causes of Overtreatment" for a model that includes "Economics" without being reductive) as this letter in the British Medical Journal shows :

As a person who follows the evolution of health care policy from the vantage point of the United States, I found BMJ's May 12 article on "Choosing Wisely in the UK" [see here ; CW is an "informed consumer" model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a culture of "more is better" fostered by such factors as "defensive medicine," "patient pressures," "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance."

Many critics of the American health care scene ascribe the problem of irrational overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to rationalizing American medical practice lies in adoption of the UK's single payer, universal coverage health care system and the UK's system of civil justice. The fact that a Choosing Wisely program is necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the UK has not found the panacea to achieving rational medical practice and that emulation of the UK methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S. either.

So, sadly, single payer as such is unlikely to solve overtreatment (although I can't think of an advocate who ever said it would).

Conclusion

If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer comes to pass, it's this one. Again Dr. Lown :

U.S. News: Problems with America's health care system are economic, but they are also human. What's been lost in modern medicine?

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good deal of overtreatment would be avoided.

NOTES

[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose. (Szabo's article considers all three, but I am focusing only on overtreatment.) American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "

taunger , October 24, 2017 at 1:41 pm

I worked as a disability advocate for years, which is a high volume practice. I read literally tens of thousands of medical records during that time. I can say, unequivocally, overtreatment is an issue.

Causes are far more difficult to deal with. The high cost of medical care is a reflection of the low quality of life many USAians are living. Listening is a good start, but far from the answer. Getting everyone in the system, so that more preventative medicine can work, avoiding patient demanded surgeries with low-probabilities of success would help as well. But even these two are just the tip of the iceberg.

In disability, chronic physical ailments mix with unemployment to form a deep pool of depressed individuals. Even with access to great healthcare (which few have), the advice to exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other arthritis and orthopedic issues, obesity, heart disease) is worth very little. In a depressed state, changing long term habits into healthy ones is very difficult, and the prevalence of patients seeing a professional to make behavioral adjustments in concert with their disease treatment is few, not counting those that show up to the psychiatrist for medication regularly.

This is why single payer, jobs guarantee, and redistribution tax policy are necessary together.

Anon , October 24, 2017 at 2:28 pm

Excellent comment. The last sentence is a comprehensive statement of actions needed to heal us (U.S.)

Certainly, some will not respond to these actions, but many will and the attempt is magnanimous for a consciously sick nation.

Arizona Slim , October 24, 2017 at 2:03 pm

Experienced this a couple of years ago.

After a car wreck, both of my parents were hospitalized for a week. During that time, I got a lot of phone calls from the hospital, and many of them related to getting my permission for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he evaded the endless tests. I guess the doctors figured that he wasn't going to live much longer, so what was the point? (He died nine months later.)

One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a colonoscopy to find out why. "Malnutrition!" I said. Loudly.

This had been a problem for years. Mom and Dad simply weren't eating enough. I'll get back to that point in a minute. But let me say that I refused the colonoscopy for my mother. In addition to being very invasive, I thought it was unnecessary.

Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated from my mother, he started eating like a horse. Gained 15 pounds in less than three months. Then he started losing weight and the nursing home sent him to hospice. In his case, that was the correct call.

Let's just say that my mother still has issues with food. Not a new problem. I remember it from my childhood. But she does have caregivers who insist on proper nutrition. And she complies.

Last time I spoke with Mom's doctor, he didn't say anything about anemia. Sounds like that's no longer a problem.

Rojo , October 24, 2017 at 2:04 pm

I think specialists are more likely to zero in on the "problem" -- the heart or lung or throat, while GP's are more likely to treat the whole person.

But GP's are often referral gateways to specialists.

Anon , October 24, 2017 at 2:47 pm

General Practice doctors are hugely important in the healthcare system. They are the traffic cops that direct patients to the appropriate specialist. They do most of the listening.

Nilavar, M. D. , October 24, 2017 at 4:58 pm

I think specialists are more likely to zero in on the "problem"

Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced only in USA after the residency training!
A Diagnostic Radiologist is called ' a doctor's doctor" since the myriad of imaging exists to help the clinical diagnosis. I came across virtually all kind of specialists, medical and surgical kind! Ifound out to whom I wouldn't even send my 'dog' for treatment!

There are ethical and morally conscious docs, but they are in the minority!VERY FEW!

A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL! Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped (needed or not), Gastroenterologist – gastro or colonoscopy, so on!

So buyer beware!

S.Nilavar. M.D.

Anonymous , October 24, 2017 at 2:07 pm

Imagine going to a restaurant where the waiter got to order for you.

"You want the steak? OK better start off with these two appetizers I think you'll like.
You'll need some wine too. There's a 1994 Cabernet that will pair great with this. I'll mark
that down. The cost? Oh don't worry about that, your dining insurance will cover it.
Now for dessert. They're all so good, I have picked out three for you. You don't need
to finish them. Now I'll just add in my customary 25% tip (I am highly trained) and we'll
call it a meal."

Vikas Saini , October 24, 2017 at 2:34 pm

As a regular lurker here, it's great to see you on this beat Lambert. We've been on this for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a series we did in the Lancet which is here:

The Drivers paper is pertinent as a description of the ecosystem of bad care.

FYI it's a deep problem of modern medicine, part of the reductionism of the Flexner paradigm that needs to change. Over treatment exists in Canada and the UK as well as in an utterly profit driven system like the US.
Single Payer will be necessary but not sufficient for this problem. Monopsony will only go so far without a revolutionary shift in culture and consciousness.

oh , October 24, 2017 at 2:50 pm

If the patient is the one who controls the payment, things may improve. Right now with insurance, there is no one to one relationship between the patient and the health provider. Insurance companies stand between the patient and payment. Even in the case of single payer, if the patient is given incentives to get second opinions and refuse unnecessary treatment, things may work better.

Lyle , October 24, 2017 at 9:38 pm

Single payer is likley to require second and if need be third opinions for non emergency surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to get) and if need be a third opinion if the first and second don't agree.

kb , October 24, 2017 at 3:03 pm

Kip Sullivan unequivocally disputes the "overtreatment" meme To the contrary, we are under treated in the US ..
Please read:
"The Health Care Mess: How we got into it and how we'll get out of it" by Kip Sullivan ..

hreikd , October 24, 2017 at 3:08 pm

Over treatment: My mom's story. From several years ago.

So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost but also great benefit to her. She had a basal cell tumor on her forehead. About the size of a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours away. She had full time help at home.

So one of my innumerable trips to help out and oversee, involved taking her to her md appointment at Brigham and Women's. She had a wonderful gerontologist, who referred me to a dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a call from the dermatologist, a young woman. Now I'm an old woman but a trained m.d. in Internal Medicine. I also knew (by then ) a great deal about dementia. And especially dementia in my particular mother.

So when the dermatologist called me she said "your mom needs a MOHS procedure". Well, a Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is awake the whole time so there's no anesthesia risk, but 8 hours on a table for a woman with advanced Alzheimer's was not going to work. I told the dermatologist that there's no way my mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, "the tumor could grow into her brain!". I said, "mom's 90, she'll be dead b/f the tumor goes anywhere!"

They were so intent on this procedure and challenged my right to speak on mom's behalf. so .. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty discharged. And complained bitterly to the referring doc when we saw him next . and he mentioned that my complaint wasn't the first.

Then I found out that the MOHS surgeons get a ton of money at the places they work, like $700,000.00 / year.

Nemo , October 24, 2017 at 3:57 pm

Thank you for sharing. It helps to know I am not alone in such experiences.

I often wonder how epidemic stories like yours are. I feel like I could write a whole book based on personal experiences along with those of family and friends. A person really has to educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have the fortune of a medical education. To have to education oneself (trying to filter all the misleading 'marketing' information and quacks out there) on complex medical procedures on top of everything else is exasperating beyond words.

How long do we, and those we care about, have to continue suffering the indignities and malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this point anymore) healthcare system?

McWoot , October 24, 2017 at 3:52 pm

I'd be surprised if a significant contributor to the "overtreatment" pie wasn't Pharma advertising

clarky90 , October 24, 2017 at 4:17 pm

The underlying premise of "modern medicine" is flawed. It dumber than Medieval bloodletting.

Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic injuries, over the last 50 years, their survival rate, in the first two years after the injury, has increased dramatically. However their long term life expectancy is about the same as it was 50 years ago.

Trends in Life Expectancy After Spinal Cord Injury
"Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post–2-year period is small and not statistically significant ."

http://www.sciencedirect.com/science/article/pii/S0003999306004060

We are bamboozled by the "complexity" of the modern medicine model, BUT, "it" is stupidly simple. They define a "normal" range of numbers. This range is arbitrary and always changing. What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?

Then they subject the patient to an array of blood tests, x rays, scans, urine tests

Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the normal range.

Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the constant unbearable pain.

Allopathic care in NZ is cheap, readily available, but a death trap for the trusting (except for catastrophic events). USAians pays hundreds of thousands of dollars for misery and drug induced ill-health.

If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive and rationed in another (USA), it is still, basically, just cat shite.

VietnamVet , October 24, 2017 at 4:40 pm

The problem is for profit healthcare. The more tests and treatments, the higher the managers bonuses. There is no regulation except for the insurance companies who are only interested in their own bottom line. The patient is not in a position to rationally oversee their care by themselves. All that matters today is profits; no matter how they are achieved. That is why American life expectancy is decreasing. Besides giving everyone healthcare; a system of primary physicians, government oversight of hospitals and care facilities plus jail time for criminals are also needed.

kareninca , October 24, 2017 at 4:43 pm

I have relatives by marriage who live in southern Indiana near the Kentucky border. They are "respectable working class," and I guess they must have good health insurance. I have never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old; they have never smoked; they go to Mass every Sunday, they have been happily married since they were young and while they don't eat health food they don't eat every meal at McDonald's. But it is surgery after surgery after surgery. They never question the doctors; they never hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy is in the hospital with infections both in his pacemaker and in his heart valve (they just replaced both; he'll probably be okay). No-one else I know has surgeries like this. I think it is a regional scam. It's true that my dad in CT has had a number of vascular surgeries, but he smoked for decades and the dire need for them has been very apparent.

Here in northern CA, I have a friend whose girlfriend's son went to the emergency room a number of years ago for a bad finger cut. He was told he needed amputation. Then they found out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab tests and probings under sedation were endless. Finally she was told to stop eating acidic food.

nihil obstet , October 24, 2017 at 4:54 pm

Reducing the profit motive as much as possible is why I would prefer a National Health Service (call it VA for all). Insurance, even if it's single payer, is still open to fraud and overtreatment. Let's try to think of medical practitioners as professionals rather than entrepreneurs, and get them to think of themselves that way. I also see it as a possible way to reduce the very high premium given to specialists, so that more would go into primary care.

Nilavar, M. D. , October 24, 2017 at 5:09 pm

In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists, orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic Radiologists etc ) always get compensated more than the primary care providers!

There are more CPT codes to charge for specialists than the GPs or FPs

Medicine is business run by 3rd parties! Vested interests won't allow any challenges to status quo, just the banking system and the FIRE Economy!

Wade Riddick , October 24, 2017 at 4:59 pm

With all due respect, if the UK system has embraced, "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance" then that means they have a substantial set of profit incentives already in place, rendering their medical system *more*, not *less*, similar to America's. They may have single payer but that just captures the monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the medical establisment (it's per se difficult to even talk about market competition when there's only one drug or treatment that will save a patient).

The unregulated private provision of public goods like medical care always leads to extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground. If you privatize schools, you get ignorance. If you privatize prisons, you get kidnapping-for-profit and the highest incarceration rate in the civilized world.

If you privatize the military, you get endless war. Why would a for-profit business ever win a war? For that matter, why would they ever lose? The war's over and they'd be out of money. You think it's just a coincidence that in the age of corporate personhood (Citizens United) and unlimited bribery of public officials, you've had two of the longest, most expensive and least determinative conflicts in our history in Iraq and Afghanistan?

You think it's a coincidence that the more unregulated "markets" we through at medicine, the more expensive our medical care becomes and the sicker we all get?

Cures don't make money. Repeat customers do.

Show me a for-profit business that's in business to go out of business and I'll show you the perfect company for insuring against social hazards.

It's simple middle-manager fraud. Politicians love privatizing government because they get to pocket the public budget. When the marines or public school principals hand tax dollars back to politicians and their cronies, everybody goes to prison. Privatize it and then you can have the contractor or charter school give you "campaign donations" – no doubt celebrating your economic genius in the process. They can hire your spouse and cousins. The contractor can even bid up the real estate and then rent it back to themselves at exorbitant prices. There are a million ways to launder the money.

Why do you think there is no transparent public accounting on most of this stuff? The budget disappears into a black hole – which, incidentally, you'll discover the minute you're in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That was the true purpose of MERS – to make good mortgage information disappear so CDO purchasers would never know what was in the mystery meat.

This is the great unraveling of Progressive Era controls on public corruption.

If you pay a dotor for every surgical screw he installs, is it any surprise then that a diabetic winds up getting several in his spine he never needed?

This is also how we have set up the aluminum and copper markets, letting speculators buy and horde commodities to drive up the price. It's also how we run drug distribution under the PBMs. PBMs provide a kickback in the form of a "stocking fee" to pharmacies which would get people sent to prison in other industries. When derivatives traders are not end consumers or producers of a commodity, they bid up prices the same way. We actually give pharmacies a profit incentive to drive cheap, effective, public domain chemicals off the market in favor of expensive, privately patented medicines. Because they are expensive, they pay a greater kickback so the pharmacy has greater incentives to stock and push it.

When railroads charged both farmers and consumers shipping and receiving food, it bankrupted both sides of the transaction by creating incentives to reduce supply in the monopoly transportation network. Reducing rail capacity bid up transportation prices and saved the company on investment. That's how you raise profits: raise prices, lower expenses. They had no rival to compete. That's why these kickbacks were outlawed. Imagine if the post office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by their "customer" (you and I).

You this same "rationing" take place now with drugs. Since legalizing PBM kickbacks, drug prices have soared and we've lived through some of the greatest drug shortages since the Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because cartels control supply and they don't like patients getting cheap, efective, public domain treatments. Go look at the availability of methotrexate over the last ten years or your platinum-based compounds. No one tells you this. It's a blip on the back page of a newspaper (and pretty soon we won't even have those). Do you think TV "news" – making its profits off drug ads – will ever talk about this?

It's a new war of enclosure – and it's far more extensive than simply drug markets. The privatizers are confiscating clean air, potable water, healthy food, public education, public policing and a host of other "general welfare" functions of the government promised us in the preamble. It all traces back to the ideology of for-profit government – which, in technical political science terms, is called fascism – when businesses own and operate the government for private gain.

By the way, we don't need less testing in medicine. We need more. I don't know a single idiot in Silicon Valley who ever said we need less data collection. The simple fact is we need to test everything in a patient and compare everything we collect across thousands of diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not to mention data processing – has been falling dramatically and yet "reformers" always stress "rationing" as the cure for health care prices. It's partly because we ration preventative medicine and diagnostics that we're in this situation.

Another great place to start would be separating diagnostics (evaluation) and treatment. Would you let the bank's chief loan officer also serve as the chief auditor? Yet we let the same doctor diagnose, treat and evaluate his own work.

As someone with serious chronic illness from these frauds, listen to me when I tell you we should be practicing medicine thousands of patients at a time with transparent public auditing and big data model building. Building my own private model of genetics from public research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the system based on whether you get the cheapest, most effective and safest treatment; in fact, I've heard of people getting fired for exactly that.

nilavar, MD , October 24, 2017 at 5:37 pm

'By the way, we don't need less testing in medicine. We need more. '

ah?

No test is 100% accurate! Every test has a potential for a FALSE positive or FALSE negative result.

False + may lead to unnecessary more testing and probably unneeded surgery! False negative gives false sense of relief!

Every test has to stand alone for specificity, sensitivity and accuracy, by statistics!

Wade Riddick , October 24, 2017 at 7:48 pm

You've answered your own question. No single measurement, in isolation, is 100% accurate. That's why we need thousands.

We need a cheap gene array chip that measures 10,000 markers in the blood and we need a big data project to match those measurements against a baseline. We need cheap, safe whole body scans. We need measurements of what every cell is up to and how they deviate from the norm.

Nobody's very angry that cell phone cameras keep getting better, yet somehow we're always upset that doctors want plenty of tests. That camera is a sensor that measures our environment and the chip gets better and cheaper each year. We need the same attitude in medicine. But then cardiologists might get upset that an immuno-assay shows you're at risk for atherosclerosis. These guys still don't want to accept that clogged arteries are an immune system problem and the immune specialists don't want to accept that it mostly gets started in the gut. And the gut guys don't want to have anything to do with immunology or cardiology.

Round and round we go

Oregoncharles , October 24, 2017 at 5:09 pm

I'll have to read the post this evening, but I have something to add to the theme:

I was in a meeting where a prominent local single-payer advocate, an emergency room doctor, told us, passionately, that administrative costs were only half the problem,. or less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of course their billing practices are a big factor.

A big advantage of single-payer is that it creates an institution with the power and motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can kill.

Mayo One , October 24, 2017 at 5:13 pm

My wife has some chronic health issues and is a regular visitor at–and occasional guest of– the Mayo Clinic, traditionally seen as the home of "integrated medicine" (i.e. the various specialties speak with each other). We count ourselves ridiculously, ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital system in the world. That said, it's amazing to both of us, even there, how silo-ed medicine has become. This silo-ing HAS to create an inordinate amount of overtreatment. The generalists, however, are left far behind in the community practices, often not able to do much beyond prescribing antibiotics and making referrals. There is a LOT of need for more holistic thinking about the patient that modern western medicine has lost, likely inadvertently, as greater knowledge leads to the need for greater specialization. The gap of some type of "master generalist" (which would of course be another layer of expense in the healthcare system) is filled either by the patient (of patient's family) or left void. As a result, there's either a huge tax of time, stress, frustration spent searching internet chat boards and medical reference sites to understand topics because it seems like no single doctor "gets it", or a hugely inefficient and potentially quite harmful medical treatment experience as each specialty chips away at their corner of the patient. I'm not sure what the answer is, but if this is the experience of a frequent Mayo Clinic patient, I'd wager that the question posed is a pretty fundamental one to the entire practice of modern medicine.

PlutoniumKun , October 24, 2017 at 5:21 pm

I would add an extra 'over' to your list – overdiagnosis.

One of the the few bright spots in published stats for the US compared to other countries is an apparent higher survival rate from cancers. I mentioned this to a relative who is a medical specialist and he just laughed. 'its not surprising' he said 'since an amazing number of those treated in the US for cancer don't actually have cancer'. Quite simply, overuse of dubious 'tests' results in a huge number of false positives for cancer. This leads to 'successful' treatments. There are many tests in the US which are simply not permitted in countries with public systems because they produce far too many false positives to justify their use, either because the cancer doesn't exist, or it is not sufficiently malignant to justify treatment (apparently there are cancers that lie dormant without ever threatening life). I'm not aware, however, if this has ever been quantified, but its certainly true that there are many testing protocols commonly used in the US which are actively recommended against in most European health systems as they are considered not just a waste of money, but actively harmful.

A relative of mine who is a very highly regarded specialist in drug prescribing practice in Europe is currently doing a one year study on practice in the US (focusing on opiates, as it happens). He said that one of the initial findings is that there is a different culture around prescribing in the US to what he is familiar with. Quite simply, US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.

Someone mentioned overuse of heart operations above. In Ireland, they developed what are called ' Sli na Slainte ' walks, which have spread worldwide. These were developed by the Irish Heart Association following complains that patients were asking for too many drugs and treatments, and not doing the simple thing which was shown to help in the aftermath of heart attacks – exercise. They are way marked walks of set distance – doctors simply prescribe the walk instead of drugs. They are hugely successful. But there is no money in it, so guess where they haven't been adopted?

*disclaimer* I should say I'm not a medical professional, but I do have an interest in the topic.

nilavar, MD , October 24, 2017 at 5:44 pm

'US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.'

But there is always another doctor 'willing' to say YES! Shopping for 'yes' doctors is NOT usual! They are called 'DR. Feel good' ;-)

Remember, Medicine is a business in America!

Chris , October 24, 2017 at 5:44 pm

Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the body's natural ability to heal itself through exercise. Pity about the commonness of common sense though, but I digress.

We all know we can live longer and avoid or postpone chronic ailments by maintaining a healthy weight and doing some exercise, particularly cardio. And our arms and legs may look the same over our declining years, but if you don't use them, you will lose them, those muscles that is.

I post. that such an ideal is too far when you are time and money poor, constantly worried and depressed

Poverty and sickness and lower mortality – they're all linked to one another. Designed and baked into the dying system

JBird , October 24, 2017 at 6:54 pm

None or too little, or too much, and very occasionally just the right amount of medical care for the lucky few. What a mess.

I'll add that the elderly, and the poor's, opinions seem to be discounted by caretakers as if you are lucky enough to be old or unlucky enough to be destitute means you're soft in the head. So if a patient can understand and communicate what they want and realistically need they have to fight to be listened too.

Steve , October 24, 2017 at 7:25 pm

Four years ago my father who was 78 at the time began having difficulty eating. He had been diagnosed with parkinson's a couple years earlier but the meds he was on were acceptable and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found tiny tumors. One couldn't be taken care of at the time and the process to his death began. No one knew how long the tumor had been there or at what speed it would grow but chemo and radiation were prescribed to make it easier to remove. This became a very long sad story which I will not go into detail on right now. The chemo made my Dad horribly sick. The radiation to pin point a tiny area less than the size of a quarter ended damaging all his organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much damage. When he asked questions about treatment he was shuffled to diffident doctors or just not answered. These were very high end NE Medical facilities. The reason he went in for digestive problems never were fixed. Had the tumors never been addressed he could very well be alive today. To date I have over 5 friends who have had a parent die not from the condition they sought help for but the radiation treatment.

mirjonray , October 24, 2017 at 8:09 pm

For me the problems start with the routine physicals which are "free" courtesy of Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds and CT scans and little surgeries to get rid of benign little thingies, before you know it you've spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This last time around my GP didn't like a few things in my lab results and I ended up with a specialist. He started off with "why are you here to see me today?" After questioning me for a little while about my (lack of) symptoms, I finally told him, "I never would have come here on my own if my doctor hadn't have sent me here."

cojo , October 24, 2017 at 9:04 pm

Dr. Lown is on to something:

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Medicine is becoming more dehumanizing. This is not only structural due to shorter patient visits, less face to face interaction, fewer family physicians treating the whole family, visiting the patient at their home, to see what their environment/neighborhood is like. It is also the way physicians practice medicine, treating patient's as mere data sets. I'm not trying to minimize data in medical decision making, but taken out of context from the human element, treating data may be misleading and may not be treating the patient's ills.

In my experience, when I see a patient coming in over and over for the same complaints, it is likley due to one of three main reasons. One, they are either being misdiagnosed and mistreated, two, they are seeking a special test or drug, or three, their symptoms are not due to an organic medical cause, but due to some sort of somatization secondary to life stressors. Trying to figure out which it is requires the clinician to listen to the patient and understand where they are coming from. Unfortunately, when a primary care physician only has 10 minutes per visit, it is much easier to order a battery of tests to not miss any important diagnoses, or to just capitulate to patient demands than to listen, and in many cases take the time to give the patient some much needed reassurance.

That being said, the patient is not always an innocent bystander in this. There are also many times that the clinician will pick up on the dynamics mentioned above, but reassurance will not satisfy the patient. The patient will demand more be done for a number of reasons. These are mostly anecdotal, such as I read an article and think I need such and such a test, or my friend/family member had this procedure done and I need it two. It sometimes takes me twice as long to explain to a patient why they don't need something done as it does as to why they do. This is a societal thing and this is linked to the problem of defensive medicine. I like to joke, that physicians always get sued for not ordering a test that may have been indicated, but rarely if ever get sued for over treating someone and then causing harm. Perhaps it has something to do with the ethos that it's better to do something and look like you're trying that to do nothing, even though that may be the best course for the patient.

In the end, I think physicians need to be better trained to listen, remember the mantra of "first do no harm", and treat each patient as if they were their close family member. The incentive structure in medicine has to also change, including the way physicians are reimbursed, as well as the way information and clinical data is sourced and distributed to avoid excess industry bias. And finally, patient's have to understand that more is not necessarily better, they or their relative do not have a god given right to every experimental, and outrageously expensive treatment available if it does not apply to them clinically and if the chances of it prolonging life are minimal.

GERMO , October 24, 2017 at 9:27 pm

Overtreatment can't possibly be as big a problem as undertreatment, at least certainly not in the world of crappy insurance or subsidized care our experience was definitely a solid reluctance to order expensive tests or to consider that the problem might be complicated and costly. Which it turned out to be, and the eventual surgery was scheduled as late as possible, as a last resort, and we had to insist on more thorough testing to get a proper diagnosis. They just wanted to save money. The tumor grew all the while this organization was hoping it was something minor. I don't want to hear about overtreatment, thanks -- it seems to always get distorted into blaming the patients for greedily consuming too much healthcare!

[Jul 25, 2017] Dont underestimate how personally piqued McCain is over President Obama, taking McCains turn, when it comes time for a vote. McCain is a nasty man

Notable quotes:
"... One of my neighbors has this to say about McCain: "I worked for American Continental. So I know what kind of a crook he is!" Said neighbor is also of the "McCain was a traitor while in North Vietnamese custody!" school. ..."
"... As to your neighbor's opinion of McCain as a collaborator, this post from Ron Unz of the Unz Review is rather eye-opening . ..."
"... McCain comes back from getting health care to help make sure others don't get health care. That's nice. ..."
"... One would have though McCain's incessant pounding on the war drums would have been enough to turn people off. I can't understand how he is so eager to send people off to repeat what happened to him. ..."
"... It probably doesn't matter whether Arizonans notice or not. McCain isn't up for reelection until 2022, so even if he survives longer than the average person with his type of cancer, in 2022 he'll still probably be dead or too weak to campaign for another term. ..."
Jul 25, 2017 | www.nakedcapitalism.com

NotTimothyGeithner , July 25, 2017 at 2:31 pm

Don't underestimate how personally piqued McCain is over President Obama, taking McCain's turn, when it comes time for a vote. McCain is a nasty man. Now that Herr Trump beat Hillary, even McCain might have done it.

Pat , July 25, 2017 at 5:11 pm

Which only proves that McCain truly is an idiot, or doesn't expect to live for another two or so years. Having a signature 'achievement' fail outright to be far more embarrassing than repealing it and having your version of healthcare, whatever it is, fail as badly or worse than ACA would, Especially since delusional folk will still think we would be in the best shape ever if only the big bad Republicans hadn't repealed Barack Obama's health reform plan. There is no such glittery unicorn if ACA continues and dies of its own weight.

(I should note that for those us not under the media induced delusion of McCain as mavericky upstanding moral leader McCain being a vindicative idiot is very old news.)

Arizona Slim , July 25, 2017 at 6:19 pm

One of my neighbors has this to say about McCain: "I worked for American Continental. So I know what kind of a crook he is!" Said neighbor is also of the "McCain was a traitor while in North Vietnamese custody!" school.

JerseyJeffersonian , July 25, 2017 at 6:51 pm

As to your neighbor's opinion of McCain as a collaborator, this post from Ron Unz of the Unz Review is rather eye-opening .

Worthy of a read, particularly for the links to researchers' posts on the matter.

JohnnyGL , July 25, 2017 at 3:09 pm

McCain comes back from getting health care to help make sure others don't get health care. That's nice.

Tim , July 25, 2017 at 3:21 pm

I noticed that irony too, I don't see how anybody in the public would NOT notice that irony, since it is a well known fact that congress gets their own health care guaranteed.

Roger Smith , July 25, 2017 at 3:40 pm

Maybe if they have brain cancer they wouldn't notice . oh.

One would have though McCain's incessant pounding on the war drums would have been enough to turn people off. I can't understand how he is so eager to send people off to repeat what happened to him.

Vatch , July 25, 2017 at 5:33 pm

It probably doesn't matter whether Arizonans notice or not. McCain isn't up for reelection until 2022, so even if he survives longer than the average person with his type of cancer, in 2022 he'll still probably be dead or too weak to campaign for another term.

Arizona Slim , July 25, 2017 at 6:22 pm

And he keeps getting weak opponents on the D side of the ballot. In 2016, it was Ann Kirkpatrick. To this day, I can't figure out why she was so compelling to the Arizona Democratic Party establishment. Oh, in 2010, you're gonna love this: Rodney Glassman. Guy didn't even complete a single term on the Tucson City Council, but he thinks he can go up against one of the best-known names in American politics. Epic fail.

[Jun 28, 2017] Prescription Drug Spending is Consuming a Bigger Share of Wages

Notable quotes:
"... The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024. ..."
Jun 28, 2017 | economistsview.typepad.com

anne

, June 27, 2017 at 05:19 PM
http://cepr.net/blogs/cepr-blog/prescription-drug-spending-is-consuming-a-bigger-share-of-wages

June 27, 2017

Prescription Drug Spending is Consuming a Bigger Share of Wages
By Brian Dew and Dean Baker

Prescription drugs are a large and growing share of national income. While it is generally recognized that drugs are expensive, many people are unaware of how large a share of their income goes to paying for drugs because much of it goes through third party payers, specifically insurance companies and the government.

The Centers for Medicare & Medicaid Services (CMS) produce projections of national expenditures on prescription drugs through 2025, along with historical estimates dating back to 1960. As shown below, prescription drug spending from 1960 to 1980 was equivalent to about one percent of total wage and salary income. In the years leading up to the passage of the Bayh-Dole act in 1980, wage income was rising faster than spending on prescription drugs. As a result, the share of wages spent on prescription drugs was actually falling, reaching a low in 1979 of 0.86%.

[Graph]

However, after 1980, prescription drug spending rose rapidly relative to wage income. The ratio of drug spending to wages rose each year from 1980 to 2007. In 2007 wage growth finally outpaced drug expenditures, with the ratio again increasing in the Great Recession. By 2010, prescription drug spending had climbed above four percent of wage income.

The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024.

While an aging population has been a factor increasing spending on drugs, demographics alone cannot explain the sharp increase in prescription drug spending. Inflation-adjusted prescription drug spending per household has increased more than eightfold since 1980, far outpacing any demographic trend surrounding age. The share of people over age 65 in the population has increased from 9.2% in 1960 to 14.8% in 2015. This can at most explain a small part of the increase in spending on drugs over this period.

[Graph]

It is important to recognize that the high cost of drugs is the result of a conscious policy decision to give drug companies monopolies in the form of patents and other forms of exclusive marketing rights. Without these protections drugs would almost invariably be cheap, likely costing on average less than one fifth as much as they do now. Even worse, the perverse incentives resulting from patent monopolies distort the research process and can lead drug companies to misrepresent evidence on the safety and effectiveness of their drugs.

[Jun 22, 2017] Playing Games with Drugs at the Wall Street Journal

Jun 22, 2017 | economistsview.typepad.com

anne , June 21, 2017 at 05:02 AM

http://cepr.net/blogs/beat-the-press/playing-games-with-drugs-at-the-wall-street-journal

June 20, 2017

Playing Games with Drugs at the Wall Street Journal

A column * in the Wall Street Journal by Dana P. Goldman and Darius N. Lakdawalla presents a case for high drug prices by making an analogy to the salaries of major league baseball players. They ask what would happen if the average pay of major league players was cut from $4 million to $2 million. They hypothesize that the current crew of major leaguers would continue to play, but that young people might instead opt for different careers, leaving us with a less talented group of baseball players. Their analogy to the drug market is that we would see fewer drugs developed, and therefore we would end up worse off as a result of paying less for drugs.

This analogy is useful because it is a great way to demonstrate some serious wrong-headed thinking. It also leads those of us who had the privilege of seeing players like Bob Gibson, Sandy Koufax, Henry Aaron, and Willie Mays in their primes to wonder if there somehow would have been better players 50 years ago if the pay back then was at current levels.

But the issue is not just how much we should for developing drugs, but how we should pay. Suppose that we paid fire fighters at the point where they came to the fire. They would assess the situation and make an offer to put out the fire and save the lives of those who are endangered. We could haggle if we want. Sometimes we might get the price down a bit and in some occasions a competing crew of firefighters may show up and offer some competition. Most of us would probably pay whatever the firefighters asked to rescue our family members.

This could lead to a situation where firefighters are very highly paid, since at least the ones who came to rich neighborhoods could count on payouts in the millions or even tens of millions of dollars. Suppose someone suggested that we were paying too much for firefighters' services and argued that there we could drastically reduce what we pay for a service we all recognize as tremendously important. Well, Goldman and Lakdawalla would undoubtedly respond with a Wall Street Journal column telling us that fewer people will want to be firefighters.

But this is really beside the point. Just about everyone agrees that it does not make sense to be determining firefighters' pay when they show up at the fire. We pay them a fixed salary. While they sit around waiting most of the time, occasionally they provide an incredibly valuable service saving valuable properties from destruction or even more importantly saving lives.

No one thinks that firefighters get ripped off because they don't walk away millions of dollars when they save an endangered family. They get paid their salary (which we can argue whether too high or too low) for work that we recognize as dangerous, but which will occasionally result in enormous benefits to society.

In the case of developing drugs, we are now largely in the situation of paying the firefighters when they show up at the burning house. As a result of historical accident, we rely on a relic of the medieval guild system, government granted patent monopolies, to finance most research into developing new drugs. These monopolies allow drug companies to charge prices that are several thousand percent ** above the free market price.

This leads to all the corruption and distortion that one would expect from a trade tariff of 1000 or even 10,000 percent. These markups lead drug companies to expend vast resources marketing their drugs. They also frequently misrepresent the safety and effectiveness of their drugs to maximize sales. They make payoffs to doctors, politicians, and academics to enlist them in their sales efforts. And, they use the legal system to harass potential competitors, often filing frivolous suits to dissuade generic competitors.

This system also leads to a large amount of wasted research spending. This is in part because competitors will try to innovate around a patent to share in the patent rents. In a world of patent monopolies it is generally desirable to have competing drugs, however if the first drug was selling at its free market price, it is unlikely that it would make sense to spend large amounts researching the development of a second, third, and fourth drug for a condition for which an effective treatment already exists, rather than researching drugs for conditions for which no effective treatment exists.

Patent monopolies also encourage secrecy in research, as drug companies disclose as little information as possible so that they prevent competitors from benefiting from their research. This also slows the research process.

The obvious alternative would upfront funding, just like firefighters are paid a fixed salary for their work. Under this system a condition of the funding would be that all the research findings are posted on the web as quickly as practical to maximize the ability of the scientific community to benefit. We already do this to some extent with the $32 billion a year that goes to the National Institutes of Health, although this amount would likely have to be doubled or even tripled to make up for the research currently supported by government granted patent monopolies. (I outline a system for this in my book "Rigged: How Globalization and the Rules of the Modern Economy Have Been Structured to Make the Rich Richer" *** - it's free.)

Anyhow, it would be good if we could be having a debate about how we finance drug research rather than just telling silly stories about baseball players salaries. Bernie Sanders, Elizabeth Warren, Al Franken, Sherrod Brown and thirteen other senators have already introduced a bill that would have the government pick up the tab on some clinical trials and then putting the rights to successful drugs in the public domain so they can be sold at generic prices. The bill also has a patent buyout fund that would accomplish the same goal.

It is absurd that we charge people hundreds of thousands of dollars for life-saving drugs that cost a few hundred dollars to produce. Too bad the Wall Street Journal has so little creativity that it cannot even imagine an alternative to a grossly antiquated institution when it comes to financing prescription drug development.

* https://www.wsj.com/articles/take-me-out-to-the-pill-game-1497913367

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** https://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

[Jun 21, 2017] Neoliberalism and opioids abuse

Jun 21, 2017 | economistsview.typepad.com

libezkova, June 21, 2017 at 07:25 PM

Over 33K people in US died of opiates overdoses in 2015 according to the Centers for Disease Control and Prevention.

Not only unemployed abuse opioids, but more and more college students and recent graduates are abusing the opioids as well, according to a survey of 1200 college aged adults commissioned the same year by Christie foundation.

Federal law does not require colleges to report drug death unless they are deemed criminal. But fatal overdoses have been rising at schools nationwide underscoring and horrifying reality of for administrators: in addition to binge drinking and marijuana, they have another crisis firmly entrenched on campus.

Now losing 30K people in one year is like small scale civil war (like the one they have in Ukraine) and in a way it is: war of wealthy and medical industrial complex against those in difficult circumstances, with dreams crashed and, especially, unemployed.

https://www.usnews.com/news/news/articles/2016-06-14/opioids-linked-with-deaths-other-than-overdoses-study-says

== quote ==

CHICAGO (AP) - Accidental overdoses aren't the only deadly risk from using powerful prescription painkillers - the drugs may also contribute to heart-related deaths and other fatalities, new research suggests.

Among more than 45,000 patients in the study, those using opioid painkillers had a 64 percent higher risk of dying within six months of starting treatment compared to patients taking other prescription pain medicine. Unintentional overdoses accounted for about 18 percent of the deaths among opioid users, versus 8 percent of the other patients.

"As bad as people think the problem of opioid use is, it's probably worse," said Wayne Ray, the lead author and a health policy professor at Vanderbilt University's medical school. "They should be a last resort and particular care should be exercised for patients who are at cardiovascular risk."

His caution echoes recent advice from the Centers for Disease Control and Prevention, trying to stem the nation's opioid epidemic. The problem includes abuse of street drugs like heroin and overuse of prescription opioids such as hydrocodone, codeine and morphine.

The drugs can slow breathing and can worsen disrupted breathing that occurs with sleep apnea, potentially leading to irregular heartbeats, heart attacks or sudden death, the study authors said.

In 2014, there were more than 14,000 fatal overdoses linked with the painkillers in the U.S. The study suggests even more have died from causes linked with the drugs, and bolster evidence in previous research linking them with heart problems.

The study involved more than 45,000 adult Medicaid patients in Tennessee from 1999 to 2012. They were prescribed drugs for chronic pain not caused by cancer but from other ailments including persistent backaches and arthritis.

Half received long-acting opioids including controlled-release oxycodone, methadone and fentanyl skin patches. Fentanyl has been implicated in the April death of Prince, although whether the singer was using a fentanyl patch, pills or other form of the drug hasn't been publicly revealed.

Long-acting opioids remain in the body longer. The study authors noted that the body's prolonged exposure to the drugs may increase risks for toxic reactions.

The remaining study patients had prescriptions for non-opioid drugs sometimes used to treat nerve pain, including gabapentin; or certain antidepressants also used for pain.

There were 185 deaths among opioid users, versus 87 among other patients. The researchers calculated that for every 145 patients on an opioid drug, there was one excess death versus deaths among those on other painkillers.

The two groups were similar in age, medical conditions, risks for heart problems and other characteristics that could have contributed to the outcomes.

The results were published Tuesday in the Journal of the American Medical Association .

The study involved only Medicaid patients, who include low-income and disabled adults and who are among groups disproportionately affected by opioid abuse.

Ray noted that the study excluded the sickest patients and those with any evidence of drug abuse. He said similar results would likely be found in other groups.

Dr. Chad Brummett, director of pain research at the University of Michigan Health System, said the study highlights risks from the drugs in a novel way and underscores why their use should be limited.

[May 31, 2017] End the Greedy Silence Dissident Voice

Notable quotes:
"... Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website . ..."
"... This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals . ..."
May 31, 2017 | dissidentvoice.org
End the Greedy Silence

Enough Already

by Ralph Nader / May 30th, 2017

It is time Americans rise up against the corruption, inefficiency, and cruelty of our healthcare system and tell its corporate captors and Congress – Enough Already!

For decades other countries have guaranteed universal health insurance for all their people, at lower costs and better outcomes (President Truman proposed it 72 years ago in the US). When are we going to break out of this taxpayer-subsidized prison built by the giant insurance companies, drug goliaths and monopolizing hospital chains?

How long is Uncle Sucker going to pay through the nose for gouging drug prices, patient-denying health insurance companies and all the brutal fine print rules in consumer contracts whose trap doors are maddening tens of millions of Americans?

Deductibles, exclusions, waivers, co-pays, corporate immunities from injured patients, disqualifying changes in patients' status and just plain stonewalling are just some examples of this cruel madness.

Not to mention the endless electronic bills with their inscrutable codes and unchallengeable charges – that is if you can get anyone on the phone to answer your questions. Billing fraud and abuses alone cost us up to $330 billion a year!

Why do we put up with "pay or die" drug prices? Why do we tolerate our fellow Americans dying in the tens of thousands each year because they cannot afford health insurance to get diagnosed and treated in time?

Do we know that the profiteering drug companies regularly are given a slew of handouts, including huge tax breaks, free drugs developed by our National Institutes of Health, and few restraints on their high pressure sales of dangerous and addictive drugs (eg opioids) or, together with their corporate middlemen, return the favor by charging Americans the highest prices in the world? Other countries put limits on such blatant greed and exploitation.

Groping for ever more profits, the big drug companies offshore production to less regulated labs in China and India, which amount to 60% of the drugs we buy and 80% of the active ingredients in all medicines sold in the US. Unpatriotic in the extreme!

Compounding these inhumane practices is a supine Congress, with few exceptions like Rep. Lloyd Doggett (D, TX), and state legislatures, misusing the power we entrusted to them. These legislators see large pharmaceutical companies as honey pots for campaign cash that work as hush money paid by hordes of drug industry lobbyists. So craven was the majority in Congress in 2003 that, when the drug benefits bill was passed, it prohibited Medicare from negotiating volume discounts for this lucrative corporate sales bonanza (Past Congresses authorized the Pentagon and Veterans Administration to bargain and they get lower prices as a result).

Despite the fact that these healthcare challenges have been dealt with more humanely and economically by other Western countries in the world, Americans are consistently told to tolerate an aggravating status quo. Scores of books, articles and television exposés highlight all the ways we're pushed around, denied, excluded, harmed, overcharged and deceived, yet so many of these authors still maintain that our system of health insurance/healthcare can't be replaced with a much better one? So these writers continue to advise us how to duck, slide and swivel our escape from a few of these commercials chains and scams.

In all the fine articles written to help consumers navigate Obamacare, Medicare, and private health plans, the authors trap themselves in this vast corporate cul-de-sac by never mentioning the way out.

That way is Single Payer or Full Medicare for all, everybody in, nobody out, with free choice of doctors and hospitals – at far lower costs, mortality and morbidity. These narrow reformers can't escape their "it ain't going to happen here" syndrome.

Really? Don't they know that the public has long viewed Single Payer favorably (including a majority of doctors and nurses), even without political leaders standing up for it or mass media reporting this proven safe path.

The surrender to corporate tyranny infects the 113 members of the House of Representatives who have co-signed HR 676 to create full Medicare for all. They signed, but then gave in to a silent resignation by not fighting for it in Congress and back home.

When the companies and their apologists argue for a "free market" approach to healthcare, you can retort – what free market? Half the money coming to these companies is from the federal, state and local governments. Taxpayers also pay tens of billions of dollars for much of the discovery and testing of drugs. Tax breaks and loopholes in patent laws block generic drugs and distort the free market.

Drug patents are by definition monopolies. Concentration by mergers and acquisitions of hospitals, clinics and physician practices (note dwindling independent cardiology practices) raise serious anti-trust issues. Fine print contract peonage takes away the consumers' freedom of contract, as do the daily buy and sell equations, so often rendered by third parties for patients. Corporate billing and other crimes are endemic. What free market?

Each of you can help the Single Payer movement build momentum. Ask your members of Congress in writing if they support HR 676 and, if not, demand their appearance in person at a town meeting arranged by people like you to answer why. If they refuse, peacefully picket their local offices.

Ask the newspapers, radio and television stations, including the culpable public radio and public television, when are they going to cover the basic full Medicare reform supported by tens of millions of their listeners and viewers?

Finally, go to the website SinglePayerAction.org to find out what other people are doing and what more you can do with your friends and co-workers.

One percent of you, together with popular backing, can make it happen, through a persistent civic hobby. Remember, you only have to turn around less than 450 members of Congress.

Enough Already?

Ralph Nader is a leading consumer advocate, the author of Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website .

This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals .

[May 29, 2017] As long as there is no countervailing force, financialization of healthcare will continue unabated

May 29, 2017 | economistsview.typepad.com

Health care -- skyrocketing cost of (USA only).

Financialization of health care makes Goldman-Sachs look like amateurs. Just read Suskind's Confidence Men -- now reading Rosenthal's American Sickness.

First hundred pages I thought her medicine was the exact same story as his Wall Street -- but hundreds more pages of her story goes on. The most unimaginable book I've read in a decade (decades?).

Single payer Medicare has none little to slow medical financialization. You can pick any health system you want from any country you like.

As long as there is no countervailing force, financialization will continue unabated. Repeat: 6% labor union density equates to 20/10 blood pressure -- starves every healthy process.

[May 05, 2017] William Binney - The Government is Profiling You (The NSA is Spying on You)

Very interesting discussion of how the project of mass surveillance of internet traffic started and what were the major challenges. that's probably where the idea of collecting "envelopes" and correlating them to create social network. Similar to what was done in civil War.
The idea to prevent corruption of medical establishment to prevent Medicare fraud is very interesting.
Notable quotes:
"... I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity. ..."
"... 500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it. ..."
"... People are so worried about NSA don't be fooled that private companies are doing the same thing. ..."
"... In communism the people learned quick they were being watched. The reaction was not to go to protest. ..."
"... Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause ..."
Apr 20, 2017 | www.youtube.com
Chad 2 years ago

"People who believe in these rights very much are forced into compromising their integrity"

I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity.

Agent76 1 year ago (edited)
January 9, 2014

500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it.

http://www.washingtonsblog.com/2014/01/government-spying-citizens-always-focuses-crushing-dissent-keeping-us-safe.html

Homa Monfared 7 months ago

I am wondering how much damage your spying did to the Foreign Countries, I am wondering how you changed regimes around the world, how many refugees you helped to create around the world.

Don Kantner, 2 weeks ago

People are so worried about NSA don't be fooled that private companies are doing the same thing. Plus, the truth is if the NSA wasn't watching any fool with a computer could potentially cause an worldwide economic crisis.

Bettor in Vegas 1 year ago

In communism the people learned quick they were being watched. The reaction was not to go to protest.

Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause......

[Apr 06, 2017] The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market.

Apr 06, 2017 | economistsview.typepad.com
anne , April 06, 2017 at 05:31 AM
http://cepr.net/blogs/beat-the-press/robert-atkinson-pushes-pro-rich-protectionist-agenda-in-the-washington-post

April 6, 2017

Robert Atkinson Pushes Pro-Rich Protectionist Agenda in the Washington Post

The Washington Post is always open to plans for taking money from ordinary workers and giving it to the rich. For this reason it was not surprising to see a piece * by Robert Atkinson, the head of the industry funded Information Technology and Innovation Foundation, advocating for more protectionism in the form of stronger and longer patent and copyright monopolies.

These monopolies, legacies from the medieval guild system, can raise the price of the protected items by one or two orders of magnitudes making them equivalent to tariffs of several hundred or several thousand percent. They are especially important in the case of prescription drugs.

Life-saving drugs that would sell for $200 or $300 in a free market can sell for tens or even hundreds of thousands of dollars due to patent protection. The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market. The strengthening of these protections is an important cause of the upward redistribution of the last four decades. The difference comes to more than $2,700 a year for an average family. (This is discussed in "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer," ** where I also lay out alternative mechanisms for financing innovation and creative work.)

Atkinson makes this argument in the context of the U.S. relationship with China. He also is explicitly prepared to have ordinary workers pay the price for this protectionism. He warns that not following his recommendation for a new approach to dealing with China, including forcing them to impose more protection for U.S. patents and copyrights, would lead to a lower valued dollar.

Of course a lower valued dollar will make U.S. goods and services more competitive internationally. That would mean a smaller trade deficit as we sell more manufactured goods elsewhere in the world and buy fewer imported goods in the United States. This could increase manufacturing employment by 1-2 million, putting upward pressure on the wages of non-college educated workers.

In short, not following Atkinson's path is likely to mean more money for less-educated workers, less money for the rich, and more overall growth, as the economy benefits from the lessening of protectionist barriers.

* https://www.washingtonpost.com/opinions/global-opinions/how-trump-can-stop-china-from-eating-our-lunch/2017/04/05/b83e4460-1953-11e7-bcc2-7d1a0973e7b2_story.html

** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

[Apr 06, 2017] Health Care Renewal Not Going to Take it Anymore - Doctors in the Pacific Northwest Unionize, Begin Collective Bargaining with Hospital Systems

Apr 06, 2017 | hcrenewal.blogspot.com
Managerialist Tactics: Outsourcing

The NYT article opened with

in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists , the hospital doctors who supervise patients' care, to a management company that would become their employer.

The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.

Outsourcing is a now familiar entry in the managerialists' playbook. It is seen more in manufacturing than in health care. Although touted as improving economic "efficiency," it also may reduce the accountability of the managers of the organization that does the outsourcing.

Pursuit of Economic Efficiency

In this case,

Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day - which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum.

It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. 'We're doctors, we're professionals,' Dr. [Rajeev] Alexander said. 'Giving me a bonus for seeing two more patients - I'm not sure I should be doing that. It's not safe .' (A hospital representative said patient safety was 'inviolate.')


A constant theme of managerialism, and the neoliberalism that underlies it, is economic efficiency. The usual narrative is that efficiency means providing better goods and services at lower costs. Instead, managerialism and neliberalism may mean decontenting goods and services so as to lower costs to the organizations providing them, but not necessarily providing more value to consumers. In health care terms, managerialism and neliberalism may lead to less accessible, more mediocre health care that increase revenue to the organizations providing it, as implied by the physicians' comments above. Making the US the most commercialized, managerialist run, and arguably neoliberal health care system among the developed countries has not led to lower costs, better access, or better health care quality.


The backstory for the outsourcing emphasizes that managerialism, and the resulting economic efficiency was indeed the goal of PeaceHealth...

In 2012, Sacred Heart's parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care . Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.

Centralization of Control

Furthermore,

The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.

'We're trained to be leaders, but they treat us like assembly line workers ,' said Dr. Brittany Ellison, a hospitalist in the group. 'You need that time with the patient,...'


A major feature of managerialism is the concentration of power within (generic) management. To quote Komesaroff(1),

In the workplace, the authority of management is intensified, and behaviour that previously might have been regarded as bullying becomes accepted good practice. The autonomous discretion of the professional is undermined, and cuts in staff and increases in caseload occur without democratic consultation of staff. Loyal long-term staff are dismissed and often humiliated, and rigorous monitoring of the performance of the remaining employees focuses on narrowly defined criteria relating to attainment of financial targets, efficiency and effectiveness.

We're Only In It for the Money

Also, the negotiations that started once the PeaceHealth physicians formed their union demonstrated a central tenet of managerialism

Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.

When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.

The hospitalists assured the administration negotiators that their concern had nothing to do with money - that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue , according to several people in the room. (The hospital declined to comment.)

Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. 'Imagine Mr. Burns,' the cartoonishly evil capitalist from 'The Simpsons,' 'sitting across the table,' he said. 'There's no way we can say, 'This isn't what we're talking about. We're not trying to get the bonus.''


Again, managerialism is based on neoliberalism, and neoliberal view is that the market rules. The market is the arbiter of success, and money is the only outcome that matters. As Komesaroff put it(1),

The particular system of beliefs and practices defining the roles and powers of managers in our present context is what is referred to as managerialism. This is defined by two basic tenets: (i) that all social organisations must conform to a single structure; and (ii) that the sole regulatory principle is the market .

Mission-Hostile Management

Never mind that the centrality of money seems entirely inconsistent with the stated mission of PeaceHealth ,

We carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way.

Ostensibly, this is accompanied by core values, such as,

Stewardship We choose to serve the community and hold ourselves accountable to exercise ethical and responsible stewardship in the allocation and utilization of human, financial, and environmental resources. and,

Social Justice
We build and evaluate the structures of our organization and those of society to promote the just distribution of health care resources.


We have frequently discussed how leadership of contemporary health care organizations often seem to act contrary to the organizations' stated mission, that is, mission-hostile management .

Value Extraction

Finally, while managerialism is ostensibly concerned with economic efficiency, whose efficiency matters. When managers address physicians' efficiency, they seem to look at amount of work done divided by the cost to the hospital of paying physicians. However, they never seem to look at their own costs, the costs of management, as being a negative.

The PeaceHealth 2014 form 990 , the latest available, states that the then CEO, Mr Alan Yordy (whose highest academic degree was an MBA, according to his LinkedIn page ) had total compensation in 2013 of $1,366,742, and 11 other managers had total compensation greater than $250,000, with 9 having total compensation greater than $500,000. Those figures should be compared to the highest compensation offered the hospitalists, a maximum of $280,000 for 182 shifts a year, eliminating all vacation and sick leave. So if it is all about the money, the managers are making the most of it.

We have discussed ad nauseum the ridiculous compensation of the leaders of health care organization, even non-profit organizations. Value extraction by top management has become a central feature of the US and global economy (look here ).

The NYT article did not discuss whether the upset hospitalists knew about their bosses' compensation. I suspect they did.

Forming a Functioning Union at the University of Washington

The media coverage of the UW housestaff unionization was less detailed. It does appear, though, that a stimulus was the pursuit of economic efficiency by UW management through squeezing the pay of housestaff, as described in the December article in the Seattle Times . In it the house staff said,

they account for about one-fifth of King County's doctors and they want higher pay, new child-care benefits and free parking. Some UW residents and fellows earn so little that they qualify for welfare programs like Temporary Assistance for Needy Families and the Seattle City Light Utility Discount Program, according to the UWHA [University of Washington Housestaff Association.]

Another article in early January, 2016 in the Seattle Times added,

The association has proposed that residents and fellows earn at least the same salary as the UW's lowest-paid physician assistants . Because the doctors in training work very long hours, they sometimes earn less than Seattle's minimum hourly wage , the UWHA has said.

The council members, in their letter to Cauce, called the situation shocking. And based on information from the UWHA, they wrote that some residents and fellows qualify for welfare programs like Temporary Assistance for Needy Families (TANF).


The Seattle articles noted that the UW housestaff may earn from just over $53,000 to just under $70,000 a year. Keep in mind, however, that under current rules, house staff may work up to 80 hours a week. So $53,000 for someone working those hours translates into $13.25/ hour, under what many people now claim is the living wage. That could be considered exploitation of workers with doctoral degrees working in often highly stressful situations where lives may be on the line. Whether there were issues other than money (and the respect it implies) involved at UW was not apparent based on the minimal press coverage.

[Apr 05, 2017] Health Care Renewal managerialism

Apr 05, 2017 | hcrenewal.blogspot.com
John Stossel Discovers Health Care Dysfunction, Blames it on "Socialists" - Like Maurice Greenberg (AIG), John Thain (Merrill Lynch), Sanford Weill (Citigroup), and David H Koch? We have been ranting for a while about the dysfunctionality of the US health care system. Unfortunately, many people only realize how bad things are when they become patients, when they have bigger things to worry about than complaining. Furthermore, even if they complain, many patients may not feel they understand enough about what has gone wrong to suggest solutions.

Bad Customer Service at New York Presbyterian

This may not apply when media pundits, especially those with strong ideological views, become patients. So this week Fox News commentator and well known libertarian John Stossel disclosed his new illness, and vented his opinions about his hospital stay . Mr Stossel unfortunately developed lung cancer, although he was optimistic about his prognosis: "My doctors tell me my growth was caught early and I'll be fine. Soon I will barely notice that a fifth of my lung is gone."

However, he was not happy about his hospital's customer service:

But as a consumer reporter, I have to say, the hospital's customer service stinks . Doctors keep me waiting for hours, and no one bothers to call or email to say, 'I'm running late.' Few doctors give out their email address. Patients can't communicate using modern technology.

I get X-rays, EKG tests, echocardiograms, blood tests. Are all needed? I doubt it. But no one discusses that with me or mentions the cost .

Also,
I fill out long medical history forms by hand and, in the next office, do it again . Same wording: name, address, insurance, etc.
And,
In the intensive care unit, night after night, machines beep, but often no one responds . Nurses say things like 'old machines,' 'bad batteries,' 'we know it's not an emergency.'
Finally,
Some of my nurses were great -- concerned about my comfort and stress -- but other hospital workers were indifferent .
Unfortunately, long wait times, poor communications, excess paperwork, and misapplied technology are all too familiar problems to those in the health care system.

Moreover, this all was happening at one of the most highly rated US hospitals,

After all, I'm at New York-Presbyterian Hospital. U.S. News & World Report ranked it No. 1 in New York .
Were "Socialist Bureaucracies" Responsible?

Mr Stossel had his own ideas about the causes of these problems.

Customer service is sclerotic because hospitals are largely socialist bureaucracies. Instead of answering to consumers, which forces businesses to be nimble, hospitals report to government, lawyers and insurance companies.

Whenever there's a mistake, politicians impose new rules: the Health Insurance Portability and Accountability Act paperwork, patient rights regulations, new layers of bureaucracy...

Also,

Leftists say the solution to such problems is government health care. But did they not notice what happened at Veterans Affairs? Bureaucrats let veterans die, waiting for care. When the scandal was exposed, they didn't stop. USA Today reports that the abuse continues. Sometimes the VA's suicide hotline goes to voicemail.

Patients will have a better experience only when more of us spend our own money for care. That's what makes markets work.

A "Socialist Bureaucracy" with a VIP Penthouse?

I am sorry to hear Mr Stossel has lung cancer, and hope that his prognosis is indeed good. I am a bit surprised that a media celebrity who became a patient found big issues with "customer service" at such a prestigious hospital. After all, many big hospitals have programs to give special treatment to VIPs (for example, see these posts from 2007 and 2011 ).

In particular, back in 2012 we posted about the contrast between the VIP services specifically at New York - Presbyterian Hospital and how poor patients are treated there. Then we quoted from a 21 January, 2012 article from the New York Times focused on the ritzy comforts now provided for wealthy (but perhaps not very sick) patients at the renowned New York Presbyterian/ Weill Cornell Hospital. It opened,

The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: 'This is like the Four Seasons - where am I?'

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble . Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, 'I'll be your butler.'

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital . Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such 'amenities units,' often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

Additional amenities include:

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium....
Also,
the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand....
An architect who specializes in designing such luxury facilities for hospitals noted:
'These kinds of patients, they're paying cash - they're the best kind of patient to have,' she added. 'Theoretically, it trickles down.'
It appears that someone failed to book Mr Stossel into the penthouse. Instead, he found out what service was like for the masses.

Perhaps this was why Mr Stossel railed at the "socialist bureaucracies" he perceived as running New York - Presbyterian Hospital. However, calling the hospital management "socialist" seems - not to put too fine a point on it - wrong.

A "Socialist Bureaucracy" Paying Millions to its CEOs?

First of all, New York Presbyterian is hardly a government agency. It is a private, non-profit corporation. Every year as such it files a form 990 with the dread US Internal Revenue Service. (The latest publicly available version is from 2013, here.) Obviously, US government agencies do not file with the IRS.

In fact, the New York Presbyterian system seems about as far from a federal government agency as one can imagine.

First, its top managers are paid like for-profit corporate executives. In 2014, we posted about the humongous compensation given to its previous, long-serving CEO, Dr Herbert Pardes, who received multi-million dollar compensation every year through his 2011 retirement, and then continued to receive several million a year from the system in his retirement. His successor, current CEO Dr Steven Corwin, received $3.6 million in 2012. (More recent compensation figures are not yet available.)

A "Socialist Bureaucracy" Dominated by Managers, with Stewardship by Top Financial Executives, and one of the Koch Brothers?

The current leadership of New York Presbyterian is dominated by businesspeople, not physicians, nurses, or other health care professionals. Only 10 of 33 listed senior leaders are health care professionals. The rest have administrative/ management or legal backgrounds and training. Many appear to be generic managers , that is, people with background and experience primarily in administration or management, but not in medicine, health care, public health, etc.

The hospital system's board of trustees was and is filled with some of the top business executives in the US, including some finance executives who have been cited as responsible for the global financial collapse/ great recession.

For example, we wrote about Mr Dick Fuld, a trustee until recently. Mr Fuld was the CEO who presided over the bankruptcy of Lehman Brothers, which heralded the beginning of the great financial crisis/ great recession of 2008 onward. Mr Fuld seemed to lack the sort of compassionate approach one might expect from someone charged with the stewardship of a big hospital system. He had once publicly said about those who sold Lehman Brother stock short: "what I really want to do is I want to reach in, rip out their heart, and eat it before they die ."

[Mar 23, 2017] A "good start" at the expence of sick people for Collectly a new medical debt collection startuo -- they now collect twise larger share of debt then before. The founder is a former CEO of a debt collection agency and collected over $100 million before

Notable quotes:
"... our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime! ..."
Mar 23, 2017 | www.nakedcapitalism.com

"All 51 startups that debuted at Y Combinator W17 Demo Day 2" [ TechCrunch ] ( day one ). This is a good one:

Collectly helps doctors collect 2x's more debt than they have before. It's a business with $280 billion sent to debt but the debt collectors only collect on average up to 20%. The founder is a former CEO of a debt collection agency and collected over $100 million before

The acerbic Pinboard comments:
D Pinboard * Follow

@Pinboard

YC so far: surreptitious recording of phone calls, bus tickets for
the starving, debt collection, go live in a box, cow collars,
chatbots

11:41 PM-21 Mar 2017

He's not wrong. (And any time you encounter an online company with a cute name that's also an adverb, like collectly , run a mile, because it's a startup that wants to harm you. Kidding! I think .)

cocomaan , March 22, 2017 at 4:03 pm

Collectly is some really depressing stuff. Wow. More from their website.

3. Transparent collection
Our intelligent software automatically reaches out to customers that didn't pay in time, so you will never need to manually chase them again. And you can see every action on every case.

Totaly fair.

Totaly fair? I had to read it twice. Is that a typo? Or does it mean something?

Next up: our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime!

Edit: Weird, this went in the wrong place. Oh well.

[Mar 22, 2017] The Men Who Stole the World

Notable quotes:
"... History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century. ..."
"... Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit. ..."
Mar 22, 2017 | jessescrossroadscafe.blogspot.com
"The problem of the last three decades is not the 'vicissitudes of the marketplace,' but rather deliberate actions by the government to redistribute income from the rest of us to the one percent. This pattern of government action shows up in all areas of government policy."

Dean Baker

"When the modern corporation acquires power over markets, power in the community, power over the state and power over belief, it is a political instrument, different in degree but not in kind from the state itself. To hold otherwise - to deny the political character of the modern corporation - is not merely to avoid the reality.

It is to disguise the reality. The victims of that disguise are those we instruct in error."

John Kenneth Galbraith

And unfortunately the working class victims of that disguise are going to be receiving the consequences of their folly, and then some.

Secure in their monopolies and key positions with regard to reform and the law, the corporations are further acquiring access to the protections of the rights of individuals as well, it appears, at least according to Citizens United .

Maybe our leaders and their self-proclaimed technocrats will finally do the right thing. I personally doubt it, except that if they do it will probably be by accident.

More likely, the right thing will eventually come about the old-fashioned way- under the duress of a crisis, and the growing protests of the much neglected and long suffering.

History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century.

... ... ...

Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit.

Better if they start breaking up corporate health monopolies and embrace real reform at the sources of the soaring costs. The US pays far, far too much for drugs and healthcare, and deregulating the markets is not the solution. We do have the example of the rest of the developed world for what to do about this. It is called 'single payer.'

But players keep on playing. And politicians and their enablers in the professions will not see what their big money donors do not wish them to see. And that is one of their few bipartisan efforts.

Might one suggest that our political animals stop trying to do all the reforming and cost controls bottom up, while applying the stimulus top down? That approach they have been flogging to no avail for about thirty years is a recipe for a dying middle class.

Here is a short video from the Bernie Sanders WV town hall that shows The Face of American Desperation. By the way, the governor of West Virginia is a Democrat. He wasn't there.

...

[Mar 17, 2017] The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

Mar 17, 2017 | economistsview.typepad.com
anne -> Fred C. Dobbs... March 16, 2017 at 06:41 AM , 2017 at 06:41 AM
The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Thousands without insurance for entire year)

2007 ( 44,088)
2008 ( 44,780)
2009 ( 48,985) Obama

2010 ( 49,951) (Affordable Care Act)
2011 ( 48,613)
2012 ( 47,951)
2013 ( 41,795)
2014 ( 32,968)

2015 ( 28,966)

anne -> Fred C. Dobbs... , March 16, 2017 at 07:26 AM
https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Percent without insurance for entire year)

2007 ( 14.7)
2008 ( 14.9)
2009 ( 16.1) Obama

2010 ( 16.3) (Affordable Care Act)
2011 ( 15.7)
2012 ( 15.4)
2013 ( 13.3)
2014 ( 10.4)

2015 ( 9.1)

[Mar 17, 2017] The difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year

Mar 17, 2017 | economistsview.typepad.com
anne : March 16, 2017 at 06:19 AM

, 2017 at 06:19 AM
http://cepr.net/blogs/beat-the-press/government-granted-patent-monopolies-cause-people-to-skip-cancer-treatments

March 16, 2017

Government Granted Patent Monopolies Cause People to Skip Cancer Treatments

National Public Radio had an interesting segment * on the difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year.

One item not mentioned in this piece is that the reason the prices of new cancer drugs is high is that the government grants companies patent monopolies. This is done as a way to finance research. In almost all cases these drugs would be available for less than a thousand dollars ** for a year's treatment if the drugs were sold in a free market.

While it is necessary to pay for research, there are more modern and efficient mechanisms than patent monopolies (see "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer" *** ).

* http://www.npr.org/sections/health-shots/2017/03/15/520110742/as-drug-costs-soar-people-delay-or-skip-cancer-treatments

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

anne -> anne... , March 16, 2017 at 06:20 AM
http://deanbaker.net/images/stories/documents/Rigged.pdf

October, 2016

Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer
By Dean Baker

The Old Technology and Inequality Scam: The Story of Patents and Copyrights

One of the amazing lines often repeated by people in policy debates is that, as a result of technology, we are seeing income redistributed from people who work for a living to the people who own the technology. While the redistribution part of the story may be mostly true, the problem is that the technology does not determine who "owns" the technology. The people who write the laws determine who owns the technology.

Specifically, patents and copyrights give their holders monopolies on technology or creative work for their duration. If we are concerned that money is going from ordinary workers to people who hold patents and copyrights, then one policy we may want to consider is shortening and weakening these monopolies. But policy has gone sharply in the opposite direction over the last four decades, as a wide variety of measures have been put into law that make these protections longer and stronger. Thus, the redistribution from people who work to people who own the technology should not be surprising - that was the purpose of the policy.

If stronger rules on patents and copyrights produced economic dividends in the form of more innovation and more creative output, then this upward redistribution might be justified. But the evidence doesn't indicate there has been any noticeable growth dividend associated with this upward redistribution. In fact, stronger patent protection seems to be associated with slower growth.

Before directly considering the case, it is worth thinking for a minute about what the world might look like if we had alternative mechanisms to patents and copyrights, so that the items now subject to these monopolies could be sold in a free market just like paper cups and shovels.

The biggest impact would be in prescription drugs. The breakthrough drugs for cancer, hepatitis C, and other diseases, which now sell for tens or hundreds of thousands of dollars annually, would instead sell for a few hundred dollars. No one would have to struggle to get their insurer to pay for drugs or scrape together the money from friends and family. Almost every drug would be well within an affordable price range for a middle-class family, and covering the cost for poorer families could be easily managed by governments and aid agencies.

The same would be the case with various medical tests and treatments. Doctors would not have to struggle with a decision about whether to prescribe an expensive scan, which might be the best way to detect a cancerous growth or other health issue, or to rely on cheaper but less reliable technology. In the absence of patent protection even the most cutting edge scans would be reasonably priced.

Health care is not the only area that would be transformed by a free market in technology and creative work. Imagine that all the textbooks needed by college students could be downloaded at no cost over the web and printed out for the price of the paper. Suppose that a vast amount of new books, recorded music, and movies was freely available on the web.

People or companies who create and innovate deserve to be compensated, but there is little reason to believe that the current system of patent and copyright monopolies is the best way to support their work. It's not surprising that the people who benefit from the current system are reluctant to have the efficiency of patents and copyrights become a topic for public debate, but those who are serious about inequality have no choice. These forms of property claims have been important drivers of inequality in the last four decades.

The explicit assumption behind the steps over the last four decades to increase the strength and duration of patent and copyright protection is that the higher prices resulting from increased protection will be more than offset by an increased incentive for innovation and creative work. Patent and copyright protection should be understood as being like very large tariffs. These protections can often the raise the price of protected items by several multiples of the free market price, making them comparable to tariffs of several hundred or even several thousand percent. The resulting economic distortions are comparable to what they would be if we imposed tariffs of this magnitude.

The justification for granting these monopoly protections is that the increased innovation and creative work that is produced as a result of these incentives exceeds the economic costs from patent and copyright monopolies. However, there is remarkably little evidence to support this assumption. While the cost of patent and copyright protection in higher prices is apparent, even if not well-measured, there is little evidence of a substantial payoff in the form of a more rapid pace of innovation or more and better creative work....

Tom aka Rusty said in reply to anne... , -1
I'm trying to imagine why anyone would write a 900 page textbook, plus add-ons (test bank, solutions manual) and then give it away.

I have refused to co-author several times because the work is agonizing, the revisions never ending, and only a few texts make anyone rich.

[Mar 14, 2017] No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist.

Mar 14, 2017 | economistsview.typepad.com
Noni Mausa : March 13, 2017 at 04:13 PM

What the wealthy right wing has decided in the past 40 years is that they don't need citizens. At least, not as many citizens as are actually citizens. What they are comfortable with is a large population of free range people, like the longhorn cattle of the old west, who care for themselves as best they can, and are convenient to be used when the "ranchers" want them.

Of course, this is their approach to foreign workers, also, but for the purpose of maintaining a domestic society within which the domestic rich can comfortably live, only native born Americans really suit.

With the development of high productivity production, farming, and hands-off war technology the need for a large number of citizens is reduced. The wealthy can sit in their towers and arrange the world as suits them, and use the rest of the world as a "farm team" to supply skills and labour as needed.

Proof of this is the fact that they talk about the economy's need for certain skills, training, services and so on, but never about the inherent value of citizens independent of their utility to someone else.

No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist. ken melvin : , March 13, 2017 at 04:48 PM

Can someone get me from $300 billion tax cut for the rich to getting the markets work for health care?
ken melvin : , March 13, 2017 at 04:54 PM
It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do. Insurance policies they don't pay out, the ones Ryan is referring to, are as good as any for scoring.
libezkova : , March 13, 2017 at 07:09 PM
"It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do."

What surprises me most in this discussion is how Obamacare suddenly changed from a dismal and expensive failure enriching private insurers to a "good deal".

Lesseevilism in action ;-)

ilsm : , March 13, 2017 at 01:41 PM
When the PPACA band-aid is pulled off the US health care mess the gusher will be blamed on "the Russians running the White House".

Cuba does better than the US despite being economically sanctioned for 55 years. Distribution of artificially scarce health care resources is utterly broken. This failed market is financed by a mix of 'for profit' insurance and medicare (which sublets a big part to 'for profit' insurance).

Coverage!!! PPACA added taxpayers' money to finance a bigger failed market. It did nothing to address the market fail!

Single payer would not address the market failure. Single payer would put the government financing most of the failed market.

Democrats have put band-aids on severe bleeds since Truman made the cold war more important than Americans.

At least we know what Trump stands for!

jeff fisher said in reply to ilsm... , March 13, 2017 at 01:58 PM
Cuba is the shining example of how doing the first 20% of healthcare well for everyone gets you 80% of the benefit cheap.

The US is the shining example of how refusing to do the first 20% of healthcare well for everyone only gets you 80% of the benefit no matter how much you spend.

jonny bakho : , March 13, 2017 at 12:09 PM
Mark's very nice argument does nothing to address The Official Trump Counter Argument:

[Shorter version: Obamacare is doomed, going to blow up. Any replacement is therefore better than Obamacare; Facts seldom win arguments against beliefs]

"During a listening session on healthcare at the White House on Monday, President Donald Trump said Republicans "are putting themselves in a very bad position by repealing Obamacare."

Trump said that his administration is "committed to repealing and replacing" Obamacare and that the House Obamacare replacement will lead to more choice at a lower cost. He further stated, "[T]he press is making Obamacare look so good all, of a sudden. I'm watching the news. It looks so good. They're showing these reports about this one gets so much, and this one gets so much. First of all, it covers very few people, and it's imploding. And '17 will be the worst year. And I said it once; I'll say it again: because Obama's gone."

He continued, "And the Republicans, frankly, are putting themselves in a very bad position - I tell this to Tom Price all the time - by repealing Obamacare. Because people aren't gonna see the truly devastating effects of Obamacare. They're not gonna see the devastation. In '17 and '18 and '19, it'll be gone by then. It'll - whether we do it or not, it'll be imploded off the map."

He added, "So, the press is making it look so wonderful, so that if we end it, everyone's going to say, 'Oh, remember how great Obamacare used to be? Remember how wonderful it used to be? It was so great.' It's a little bit like President Obama. When he left, people liked him. When he was here, people didn't like him so much. That's the way life goes. That's human nature."

Trump further stated that while letting Obamacare collapse on its own was the best thing to do politically, it wasn't the right thing to do for the country.

http://www.breitbart.com/video/2017/03/13/trump-republicans-putting-bad-position-repealing-obamacare/

[Mar 07, 2017] Americans' Challenges with Health Care Costs

Notable quotes:
"... Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items. ..."
"... Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine. ..."
Mar 07, 2017 | economistsview.typepad.com
anne : March 06, 2017 at 11:40 AM , 2017 at 11:40 AM
http://kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/

March 2, 2017

Americans' Challenges with Health Care Costs
By Bianca DiJulio, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie

As lawmakers debate the future of the country's health care system and outline plans to repeal and replace the Affordable Care Act, much of the current debate surrounds how to change or eliminate the health insurance marketplaces developed under the ACA where individuals eligible for financial assistance could compare plans and purchase insurance. While this is an important source of coverage for some, the vast majority of Americans with insurance have coverage from other sources, such as an employer, Medicaid or Medicare, and the public's top priority for lawmakers is reducing what Americans pay for health care. Two recent Kaiser Health Tracking Polls take stock of the public's current experience with and worries about health care costs, including their ability to afford premiums and deductibles. For the most part, the majority of the public does not have difficulty paying for care, but significant minorities do, and even more worry about their ability to afford care in the future. Some of the key findings include:

Four in ten (43 percent) adults with health insurance say they have difficulty affording their deductible, and roughly a third say they have trouble affording their premiums and other cost sharing; all shares have increased since 2015.

Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items.

Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine.

Even for those who may not have had difficulty affording care or paying medical bills, there is still a widespread worry about being able to afford needed health care services, with half of the public expressing worry about this.

Health care-related worries and problems paying for care are particularly prevalent among the uninsured, individuals with lower incomes, and those in poorer health; but women and members of racial minority groups are also more likely than their peers to report these issues....

Peter K. -> anne... , March 06, 2017 at 11:48 AM
"For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items."

That's what the neoliberals like our dear trolls kthomas and PGL want.

They're in the pocket of the lobbyists.

[Mar 07, 2017] Uncertainty and the Welfare Economics of Medical Care

Mar 07, 2017 | economistsview.typepad.com
anne -> anne... March 06, 2017 at 05:11 PM , 2017 at 05:11 PM
https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

December, 1963

Uncertainty and the Welfare Economics of Medical Care
By KENNETH J. ARROW

I. Introduction: Scope and Method

This paper is an exploratory and tentative study of the specific differentia of medical care as the object of normative economics. It is contended here, on the basis of comparison of obvious characteristics of the medical-care industry with the norms of welfare economics, that the special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and in the efficacy of treatment.

It should be noted that the subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public health, which I propose to discuss.

The focus of discussion will be on the way the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, if at all. The "norm" that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them if each individual in the market offered or purchased services at the going prices as if his decisions had no influence over them, and the going prices were such that the amounts of services which were available equalled the total amounts which other individuals were willing to purchase, with no imposed restrictions on supply or demand.

The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. In particular, we can state the following well-known proposition (First Optimality Theorem)....

a

[Mar 07, 2017] Notes on US healthdoesntcare

Mar 07, 2017 | economistsview.typepad.com
libezkova : March 06, 2017 at 08:41 PM

The problems with US Healthdoesn'tcare started around 1980.

What we observe now (completely broken and corrupt to the core system) is the result of long term term slow deterioration.

Now the US Healthdoesn'tcare in many cases represent the completely opposite practice to healthcare -- health racket.

And they even created their specialized firms that help to extract maximum dollars for private providers.

An interesting example of how pervert the USA healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically are always "out of network" and after providing services (often non-essential and equal to the ride to ER, but mostly unavoidable as soon as 911 service or traffic police is involved, especially for those who are in this situation for the first time ) they bill an outrageous amount to lemmings who do not know how to fight the system.

Average private ambulance bill is probably around $5K in the USA. And that if this was just a ride to ER.

If you have insurance it will pay around the same as Medicare and your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states (CA, partially NY), but still is legal in most other states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/). And look who is at the helm of this wonder of neoliberal health industry (pretty profitable -- currently bills over 120 million in revenue annually taking in probably lion share of that) -- James J. Loures, President & CEO

James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region.

Is not neoliberalism wonderful social system ?

So when somebody is taking about destruction of the US health care system by Trump one needs to understand that there is not much left to destruct. Most of the heavy lifting was done by previous administrations.

Including Obama with his coward method of betrayal of his voters and serving medical industrial complex.

Trump is bad, but to claim that because of that Obama was good is silly. He was just a perfect example of neoliberal "bait and switch" politician.

B.T. : , March 06, 2017 at 07:51 PM
So it's like the ACA?

Or it's terrible?

Make up your minds neoliberals. Since you didn't want single payer.

libezkova -> B.T.... , March 06, 2017 at 09:12 PM
It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ( http://khn.org/morning-breakout/health-care-billing-errors/ )

"thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones."

Private medical industry and insurance are symbiotic in their desire to milk patients out of their money in the most efficient way possible.

And while those "death panel" decisions are very difficult indeed, fraud is rampant and they are very successful in over-billing patients.

This symbiosis is very similar in nature to what we observe with body shops and car insurance.

[Mar 06, 2017] Something about the meaning of life under neoliberalism

Notable quotes:
"... Probably the most telling example on neoliberal transformation is transformation of healthcare. ..."
"... Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing. ..."
"... Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles. ..."
"... In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests). ..."
"... James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. ..."
Mar 03, 2017 | economistsview.typepad.com
libezkova : March 03, 2017 at 03:51 PM
Something about the "meaning of life" under neoliberalism

Probably the most telling example on neoliberal transformation is transformation of healthcare.

http://onlinelibrary.wiley.com/doi/10.1111/maq.12161/full

== quote ==

Several anthropologists have written about how "market ideology and corporate structures are shaping medicine and health care delivery" (Horton et al. 2014; Lamphere 2005; Rylko-Bauer and Farmer 2002:476).

Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing.

The information that is produced in technical public health policy terms, and, I would add, in technical legal terms, is "a knowledge-making practice that creates information about the health care system and for managing the system in new ways" (Mulligan 2010:309).

Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles.

In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests).

According to Fassin (2009), Foucault's undeveloped concept of a Politics of Life can illuminate how in regulating populations and normalizing societies, moral ideas about the meaning of life and about how life is valued are enforced.

An understanding of moral definitions of human life must take into account how history becomes embodied, which then illuminates the political tensions that support differential values by which life is organized, represented, and responded to, for example through public policy (Fassin 2007).

== end of quote ==

See also

https://www.youtube.com/watch?v=TsoZeg6CDRY

An interesting example of how pervert the healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically always "out of network" and after providing services (often non-essential) bill outrageous amount to lemmings who do not know how to fight the system. Average private ambulance bill is probably around $5K in the USA. If you have insurance your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states, but still is legal in most states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/)

== quote ==

Revenue Guard Executive Team

James J. Loures, President & CEO
James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. After merging MultiCare with the publicly traded Rural-Metro in 2001, James then founded Revenue-Guard in 2004. The company has grown to be a premier provider of EMS revenue cycle and management services in the hospital marketplace, and currently bills over 120 million in revenue annually for their clients. James studied economics at Rutgers University .

Steven J. Loures, Co-Founder and Chief Operations Officer
Steven Loures has 30 years of experience in the Emergency Medical Services / Mobile Health Services field and is considered an expert in revenue cycle, compliance and improving ambulance service operating margins. His real-world revenue cycle knowledge combined with 20 years of managing ambulance operations uniquely differentiates himself with a comprehensive industry perspective. His leadership has provided client confidence to initiate targeted change knowing his proven track record. He is the point of contact for all new and existing clients.

Prior to his current role Steven was the New Jersey Division General Manager of Rural Metro Ambulance. Rural Metro is a large nationwide provider of Emergency Medical Services. He was responsible for oversight of 350 employees, 6 operating locations in three states including New Jersey, Pennsylvania and New York City. Additionally, Steven's responsibilities included all budgets, revenue cycle management, billing compliance, and Sarbanes Oxley financial controls.

Prior to Rural Metro Steven was a Commercial Lear Jet Pilot. The operation provided nationwide long distance critical care air ambulance services. Steven graduated from Embry-Riddle Aeronautical University, Daytona Beach Florida with his Federal Aviation Administration Commercial, Multi-Engine, and Instrument ratings. Early in his career path Steven was a certified NJ paramedic at age 21 and one of the youngest certified paramedics in New Jersey.

Stephanie Dall, Vice President of Finance
Stephanie joined Revenue-Guard in 2005 and is responsible for Finance, Administration, Compliance and client reporting. She has 20 years experience in finance and administration with Rural-Metro Inc. the leading EMS provider in the nation. Stephanie develops budgets and establish performance metrics for Revenue-Guard. Stephanie has a bachelors degree in accounting from Rutgers University.

Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale, Arizona. She handles all system customizations, ePCR integration and client support services. Jen studied at Pace University in New York City.

[Mar 03, 2017] U.S. Medical Coding System

Notable quotes:
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
Mar 03, 2017 | www.nakedcapitalism.com
From my review of Akerlof and Shiller's Phishing for Phools , November 25, 2015 :

As businesspeople choose what line of business to undertake - as well as where they expand, or contract, their existing business - they (like customers approaching checkout) pick off the best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are quickly taken off the table, leading to a situation where such opportunities are hard to find. This principle, with the concept of equilibrium it entails, lies at the heart of economics.

The principle also applies to phishing for phools. That means that if we have some weakness or other - some way in which we can be phished for fools for more than the usual profit - in the phishing equilibrium someone will take advantage of it . Among all those business persons figuratively arriving at the checkout counter, looking around, and deciding where to spend their investment dollars, some will look to see if there are unusual profits from phishing us for phools. And if they see such an opportunity for profit, that will (again figuratively) be the "checkout lane" they choose.

And economies will have a "phishing equilibrium," in which every chance for profit more than the ordinary will be taken up.

We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or, in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall see, plenty of "opportunities for unusual profits" exist in medical coding.

... ... ...

Here is the medical coding process, from the coders perspective, as described by MB-Guide, a site for aspiring medical coders :

Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid.

Hmm. "Their" benefit. Here are the guidelines:

I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. The Denver Post gives a horrific example:

Miscoding Fictions, frauds found to abound in medical bills

A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.

Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy.

Finally, there's "upcoding," and if you are reminded of "upselling" you are exactly right. The Center for Public Integrity :

But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.

The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.

Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system :

"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today's complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. "Until the fraud is detected in these bills the cost of health care is just going to increase. It's not accidental. We've been fighting these overcharges they continue to happen and we continue to get them removed from bills." These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That "mysterious code" is (now) ICD-10, and it's the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post :

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts.

Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors.

It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse." Others say that errors occur largely because of "the complexity of deciphering bills and claims weighted down by complex codes."

Even if the "trade group" is talking it's book, it's still quite a book . NBC :

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

Neoliberal "Consumer"-Driven Solutions

My guts have started to gripe, so I won't go into detail about how you too, the citizen , can learn medical billing codes if you want to dispute your bill. See this cheery post from NerdWallet on "How to Read Your Medical Bill :

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Your medical bill is going to be chock-full of codes and words you may not understand, so the first step is gathering resources that will translate them into plain English.

Ivy , March 2, 2017 at 2:29 pm

One useful adjunct to the coding discussion concerns other billing details such as meds. There is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix) or $26 for a single Tylenol, then something is not right. Of course, that does not include any allocation for nurses, pharmacy or other potential costs, since those are rolled into other line items to decipher. When hospital billing reps are asked about the reasonability and basis of their charges, they spout the canned line about being in line with their local competitors.

Why not have some program with mutual insurance companies, removing in theory some of the profit that is driving the typical health care insurers?

TheBellTolling , March 2, 2017 at 2:31 pm

Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image).

ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims.

_________________________________

Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has conditions that will cost more) each member is and give insurers more or less money based on the average risk scores of their members. Since it relies on coding this system is also subject to gaming.

In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability to use some adjustment factors to MA payments to address the issue but I don't really know how effective it is.

In ACA this is done relative to all the other insurers in the individual/small group market(so all the money is changing hands between the insurers). More established plans generally do better since they have more data on members from before ACA to make sure they get coded in addition to resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and newer plans like co-ops.
_____________

[Mar 03, 2017] How to Read Your Medical Bill

Notable quotes:
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
NerdWallet
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in names and addresses result in huge billing complications. Before you move on, make sure your name, address, insurance information and dates of care are correct on the top of the bill.

header

When you receive inpatient or outpatient care, the first statement you'll receive is most likely a summary bill. Often, but not always, health care providers will send only a summary of charges with a final charge at the end. The body of the bill has a few generic categories and no codes, looking something like this:

summarybill

That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this:

detailed

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Next, know what the codes are for

Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's more than one type of code that may be listed on your bill.

svccode

HCPCS Level I, or CPT Codes, are universal, used by all providers in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed as service codes.

svccode2

HCPCS Level II Codes identify supplies or products used during your visit. These codes often start with a letter, rather than a number, but are also referred to as service codes.

[Feb 27, 2017] Why Markets Can't Cure Healthcare

Feb 27, 2017 | economistsview.typepad.com
anne -> anne... February 26, 2017 at 02:07 PM , 2017 at 02:07 PM
http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/

July 25, 2009

Why Markets Can't Cure Healthcare
By Paul Krugman

Judging both from comments on this blog and from some of my mail, a significant number of Americans believe that the answer to our health care problems - indeed, the only answer - is to rely on the free market. Quite a few seem to believe that this view reflects the lessons of economic theory.

Not so. One of the most influential economic papers of the postwar era was Kenneth Arrow's "Uncertainty and the Welfare Economics of Health Care," * which demonstrated - decisively, I and many others believe - that health care can't be marketed like bread or TVs. Let me offer my own version of Arrow's argument.

There are two strongly distinctive aspects of health care. One is that you don't know when or whether you'll need care - but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor's office; and very, very few people can afford to pay major medical costs out of pocket.

This tells you right away that health care can't be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can't just trust insurance companies either - they're not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers' point of view - they actually refer to it as "medical costs." This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there's a widespread sense that our fellow citizens should get the care we need - not everyone agrees, but most do - this means that private insurance basically spends a lot of money on socially destructive activities.

The second thing about health care is that it's complicated, and you can't rely on experience or comparison shopping. ("I hear they've got a real deal on stents over at St. Mary's!") That's why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don't trust them - they're profit-making institutions, and your treatment is their cost.

Between those two factors, health care just doesn't work as a standard market story.

All of this doesn't necessarily mean that socialized medicine, or even single-payer, is the only way to go. There are a number of successful healthcare systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn't work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

* https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

anne -> anne... , February 26, 2017 at 02:44 PM
Correcting again and continuing:

Though Krugman always praises the work of Arrow on healthcare markets, Krugman never seems much been influenced by the work.

Though praising Arrow on healthcare markets, Krugman seemingly has spent no time on or possibly has dismissed research affirming Arrow and has not supported the sorts of healthcare insurance systems that would follow from accepting the work of Arrow:

https://promarket.org/there-is-regulatory-capture-but-it-is-by-no-means-complete/
/
March 15, 2016

"There Is Regulatory Capture, But It Is By No Means Complete"
By Asher Schechter

Kenneth J. Arrow, one of the most influential economists of the 20th century, reflects on the benefits of a single payer health care system, the role of government and regulatory capture.

Mr. Bill : , February 26, 2017 at 03:32 PM
So Anne, what your saying is that "health care" is a monopolistic industry that makes more money by restricting care and charging more ? Allowing people that can't afford to live, too die?

Well. yes, I agree with your presumed hypothesis, and I admire your boldness for stepping out in front of this moving freight train, risking your beloved tenure.

To me ? Thanks for asking.

I think that the 3 % administrative costs of the existing single payer system are more pareto optimal than the 25 % that the monopolists' extract. What do I know. This is America. Dumb is not an option.

anne : , February 26, 2017 at 06:33 PM
Turning again to Kenneth Arrow and healthcare markets, assuming that Arrow was correct for all these years, and subsequent research repeatedly has confirmed Arrow, then a typical American market-based healthcare insurance system is going to prove unworkable. Why then has the work of Arrow which is at least superficially so broadly praised by economists not been more influential in forming policy?
libezkova -> anne... , February 26, 2017 at 07:12 PM
"It is difficult to get a man to understand something, when his salary depends on his not understanding it."

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

[Feb 26, 2017] Clowbacks to benefits manager is like crack cocaine

This is racket. Plain and simple.
Notable quotes:
"... Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask. ..."
"... "Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate." ..."
"... Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks. ..."
"... The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively." ..."
"... Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws. ..."
"... Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals. ..."
"... The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price. ..."
Feb 26, 2017 | economistsview.typepad.com
im1dc: February 24, 2017 at 05:26 PM
Real World Economics

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

https://www.bloomberg.com/news/articles/2017-02-24/sworn-to-secrecy-drugstores-stay-silent-as-customers-overpay

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

by Jared S Hopkins...February 24, 2017...9:52 AM EST

> Gag clauses stop pharmacists from pointing out a cheaper way

> Cigna, UnitedHealth and Humana face at least 16 lawsuits

"Eric Pusey has to bite his tongue when customers at his pharmacy cough up co-payments far higher than the cost of their low-cost generic drugs, thinking their insurance is getting them a good deal.

Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask.

"Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."

Graphic

Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks.

"It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get enough."

The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively."

Racketeering Accusations

Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws.

"Pharmacies should always charge our members the lowest amount outlined under their plan when filling prescriptions," UnitedHealthcare spokesman Matthew Wiggin said in a statement. "We believe these lawsuits are without merit and will vigorously defend ourselves."

Mark Mathis, a Humana spokesman, declined to comment. Matt Asensio, a Cigna spokesman, said the company doesn't comment on litigation.

"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the Pharmaceutical Care Management Association, said in a statement.

Read more: Escalating U.S. drug prices -- a QuickTake explainer

Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals.

The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price.

"There's this whole industry that most people don't know about," said Connecticut lawyer Craig Raabe, who represents people accusing the companies of defrauding them. "The customers see that they go in, they are paying a $10 co-pay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 co-pay."

On Feb. 10, a customer at an Ohio pharmacy paid a $15 co-pay for 15 milligrams of generic stomach medicine pantoprazole that the pharmacist bought for $2.05, according to receipts obtained by Bloomberg. The pharmacist was repaid $7.22, giving him a profit of $5.17. The remaining $7.78 went back to the benefits manager.
Opaque Market

Clawbacks are possible because benefit managers take advantage of an opaque market, said Hayes, the Illinois consultant. Only they know who pays what.

In interviews, some pharmacists estimate clawbacks happen in 10 percent of their transactions. A survey by the more than 22,000-member National Community Pharmacists Association found 83 percent of 640 independent pharmacists had at least 10 a month.

"I've got three drugstores, so I see a lot of it," David Spence, a Houston pharmacist, said in an interview. "We look at it as theft -- another way for the PBMs to steal."

Lawsuits began in October in multiple states, and some have since been consolidated. Most cite an investigation by New Orleans television station Fox 8, which featured interviews with Louisiana pharmacists whose faces and voices were obscured.
Tight Restrictions

Many plans require pharmacies to collect payment when prescriptions are filled and prohibit them from waiving or reducing the amount. They can't even tell their customers about the clawbacks, according to the suits. Contracts obtained by Bloomberg prohibit pharmacists from publicly criticizing benefit managers or suggesting customers obtain the medication cheaper by paying out of pocket.

Pharmacists who contract with OptumRx in 2017 could be terminated for "actions detrimental to the provider network," doing anything that "disparages" it or trying to "steer" customers to other coverage or discounted plans, according to an agreement obtained by Bloomberg.

"They're usually take-it-or-leave-it contracts," said Mel Brodsky, who just retired as chief executive officer of Pennsylvania's Keystone Pharmacy Purchasing Alliance, which buys drugs on behalf of independent pharmacies.

OptumRx is among the three largest benefit managers that combine to process 80 percent of the prescriptions in the U.S. The other two, Express Scripts Holding Co. and CVS Caremark, haven't been accused of clawbacks. CVS doesn't use them, it said in a statement. Express Scripts is so opposed that it explains the practice on its website and promises customers will pay the lowest price available.
Potential Death Blow

Pharmacies fear getting removed from reimbursement networks, a potential death blow in smaller communities. But some pharmacists jump at opportunities to inform customers who question their co-pay amounts.

"Most don't understand," said Spence, who owns two pharmacies in Houston. "If their co-pay is high, then they care."

States are responding. Last year, Louisiana began allowing pharmacists to tell customers how to get the cheapest price for drugs, trumping contract gag clauses. In 2015, Arkansas prohibited benefit managers and pharmacies from charging customers more than the pharmacy will be paid.

"The consumers don't know what's going on," said Steve Nelson, a pharmacist in Okeechobee, Florida. "We try to educate them with regards to what goes into a prescription, OK? You've got to kind of tip-toe around things."

ilsm -> im1dc... , February 24, 2017 at 07:08 PM
pharma to USG

like drug cartel in Mexico

except no briefcases

im1dc -> ilsm... , February 24, 2017 at 07:47 PM
That's a valid observation.

[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.