Slightly Skeptical View on Health insurance

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It's hard to find products, services and companies that provide honest health service, good monitoring devices and, in general, quality products. This is especially true about medical insurance. Everything (or almost everything is spoiled by obsessive, destructive marketing). Not only USA health system is drug obsessed and test driven to the extent that serious mistakes are possible, it is based of strange symbiosis between doctors and health insurance companies in which each party tries to fool the other. In addition, many doctors became more pharmacy salesmen then real health specialists.  This father complicates the picture. 

In fact, anybody with health problems need to participate in complex poker match between insurance and doctors where you just a minor card.  There are several dangers here

Distortions created by the US healthcare model

This is a very complex issue but some visible problems are as following:

None of these key issues is addressed by the new legislation, hence the support from the Pharmaceutical Companies and Insurers. Nothing will change and the US will continue to pay double the share of GDP with worse outcomes in comparison to other developed countries.


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[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.

[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?

[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.

[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......

[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 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/

[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 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 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Nov 05, 2015] Fake herbal supplements are more common then you think

observer.com

observer.com

Earlier this year, the New York AG investigated supplements at major retailers and found that four out of five didn't contain any of the labelled herbs. They contained "cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies." We're not talking fly-by-night Internet products; these are glossy bottles of so-called Gingko Biloba and Echinacea and Garlic, sold in stores like GNC and Target and Walgreens, with relaxing names like "Herbal Plus" and "Spring Valley":

1-rMEC1moEKkOBfuiGvH8Czg

When you buy a supplement, then, you're effectively on your own - not just in determining whether the supplement is safe and effective, but even in deciding whether you're eating what you think you're eating. Reload's packaging suggests it's an "herbal blend" full of plants like Gingko Biloba and Saw Palmetto, but tests show that it actually contains sildenafil, the strong prescription chemical found in Viagra itself.

This is a much freer market than people are accustomed to when they purchase anything from a reputable retailer, let alone something they plan to swallow. Absent stricter regulation, busy citizens count on the media to inform.

[Oct 28, 2013] OBoZoCaRe BoNaNZa!

Zero Hedge

Below is Kunstler's description of our medical situation. All that needs to be pointed out is that the republicans are primarily the ones responsible for opposing the kinds of fixes that would have gone a long ways to remedy the situation. A single care provider approach means cutting out the sleazy tribe of middle-men who make our way of fleecing the ailing public so profitable. The prime directive of the republican party is at all costs protect the unholy wealth of those who already have most of it...

The ObamaCare piece of the picture is a mere pathetic soap opera compared to the first two quandaries. The 2000-page law did nothing to address the core tragedy of medicine in America - namely, that it has evolved into a hideous hostage racket. You go to a hospital with a terrifying illness and you are susceptible to fleecing by the so-called "care-givers" for the promise that you may get to live. No prices for treatment are never discussed. They are presumed to be astronomical - but who cares if you end up dead, and if you do get to live, you'll figure that out later. If you hold an insurance policy, these charges will be subject to a fake negotiation between grifting insurance companies and grifting hospitals, physicians, and drug companies. The price "settlements" are only slightly less a joke than the actual charges, and are obfuscated in documents designed to bewilder even well-educated policy-holders.

Even if you are insured, the charges may bankrupt you. A typical one-day charge for "room and board" in a non-specialized hospital in-patient bed runs $23,000 at my local hospital. For what?

Half a dozen blood-pressure checks and three bad meals? You can be sure that ever-fewer families will be able to fork over $12,000-a-year for basic coverage.

The ObamaCare legislation and its laughable rollout of a useless website is just a punctuation mark at the end of the soap opera script.

The result eventually will be the complete implosion of the medical racket and a return to a very primitive clinic system, with payment in chickens or cords of stove-wood. The smaller number of surviving humans will surely enjoy better health, and greater piece of mind, when this monster racket expires of inertia, bad faith, and deceit.

[Nov 03, 2011] The profit in keeping you ignorant by Wendell Potter

iWatch News

Health insurance industry and its corporate allies are fighting requirement that policies be understandable By Wendell Potter6:00 am, October 31, 2011 Updated: 1:21 pm, October 31, 2011 PrintE-mail6 inShare. Columnist Wendell Potter Robin Holland If you have no idea what you're paying good money for when you enroll in a health insurance plan, there's a good reason for that: insurers profit from your ignorance. And they're waging an intense behind-the-scenes campaign to keep you in the dark.

In my first appearance before Congress after leaving the insurance industry, I told members of the Senate Commerce Committee that insurers intentionally make it all but impossible for consumers to find out in advance of buying a policy exactly what is covered and what isn't and how much they'll be on the hook for if they get sick or injured. Insurers are quite willing to provide you with slick marketing materials about their policies, but those materials are notoriously skimpy when it comes to useful information. And the documents they provide after you enroll are so dense few of us can understand them.

In the months following my Senate testimony, lawmakers drafting health reform legislation included a provision requiring insurers to both provide comprehensible disclosures of health plan benefits and make that information available to anyone shopping for coverage. Despite repeated attempts by industry lobbyists to get that provision stripped out of the final bill, the Affordable Care Act as signed by President Obama last year requires that all private health plans provide consumers with a concise and understandable Summary of Benefits and Coverage (SBC) form. In addition, they must provide a uniform glossary of medical and insurance terms.

If you think that sounds like a reasonable request, you're not an insurance company executive who is rewarded more for meeting Wall Street's profit expectations than assuring that consumers know what they're buying.

Now the Obama administration is trying to figure out how to enforce this new requirement, and so health insurers and their allies have launched a full-court press to persuade government officials to gut it by exempting policies sold where people work. Because the vast majority of Americans who have coverage get it through their employers, this would mean that most of us would, for all practical purposes, continue to have to buy a pig in a poke.

Fortunately there are several organizations, including Consumers Union, publisher of Consumer Reports , that are fighting the good fight. They're demanding that Obama officials write the regulations to apply to all health plans, regardless of whether they are sold on the individual market or through employers, unions or other groups. They insist that Congress intended for the standard form, which would allow "apples-to-apples" comparisons of health plans, to apply across the board.

As Consumers Union noted in comments sent to the administration, the booklet describing benefits that most employers currently provide their workers "is a bulky, legalistic document that few consumers can understand." It cited one study which concluded that the typical benefit description document provided by employers is written at a college reading level. Most Americans have trouble understanding information written above the 6 th to 8 th grade level.

Insurers and their corporate allies, including the U.S. Chamber of Commerce and the National Association of Health Underwriters, are claiming in comment letters to the administration that providing a uniform, simplified and understandable version of those documents would cost so much money they would have to increase premiums.

America's Health Insurance Plans (AHIP), the lobbying and PR group for insurers that says it represents more than 1,300 health plans covering 200 million people, contends that the cost of implementing the proposal would be $188 million. In addition, AHIP says, the annual cost of providing the information would be $194 million. Would insurers consider absorbing those costs? Of course not.

"The benefits of providing a new summary of coverage document, in addition to what is already provided to consumers, must be balanced against the increased administrative burden that drives up costs to consumers and employers," AHIP said in its letter.

Nonsense. Consider this: the five largest insurers (UnitedHealth, WellPoint, Aetna, CIGNA and Humana) over the past week have reported profits exceeding $2.6 billion for just the three months that ended September 30, 2011. Over the past 10 years, those five companies have recorded profits of more than $50 billion. Imagine what the total would be if you added in the profits of the other 1,295 health plans AHIP says it represents.

The industry could even pass a hat among the CEOs of those big insurers and come up with the additional money without any one of them giving until it really hurt. UnitedHealth's Stephen J. Hemsley is the highest paid CEO in America, according to Forbes magazine. He hauled in more than $100 million last year alone. When H. Edward Hanway, my former CEO at CIGNA, retired at the end of 2009, he walked out the door with $111 million. When you consider the money those two guys have made over the years, they alone could cover the cost of providing consumers with information they can understand.

I'd advise everyone to keep their eyes on this skirmish. If the administration caves to the insurers' demands on this, we'll know who really is calling the shots when it comes to implementing health care reform.

[Feb 08, 2011] guest-post-why-small-business-isnt-hiring-and-wont-be-hiring

by cxl9
on Tue, 02/08/2011 - 12:49
#943358

$1000/month for health coverage? Really? I am a 43-year old man who pays $369/mo. for a Kaiser gold policy + prescription. A young person could expect to pay half that. Anyone who believes health care is overpriced or unaffordable is simply hoping the government will force someone else will pay his medical bills.

by docj
on Tue, 02/08/2011 - 13:01
#943378

Good luck finding a "state approved" health insurance policy in the People's Republic of MA for under $1K/mo. (Thanks for that, Mitt Romney.)

by ThirdCoastSurfer
on Tue, 02/08/2011 - 14:31
#943751

Thanks to QE2 I have High Blood Pressure and "suddenly" don't qualify for traditional insurance. I applied for and qualified for "Obama Care" through www.pciplan.gov.

For $400 a month it carries a $2,000 deductible and a $5950 Out of Pocket max (OOP). http://www.pciplan.com/forms/pdfs/2011BenefitsSummary.pdf

So, from Year to Year, I can expect to pay $4800 in premium and $2,000 deductible equaling $6,800 before coverage begins and then I'll pay 20% of the next $19,750 before the OOP max is reached.

It was hard for me to fathom why I would chose (or in 2014 be forced) to accept such terms rather than just pay cash in the hopes that no one annual bill would amount to more than $10,750 (Premium + OOP) until I looked at the cost of random things like an appendectomy or a ER visit for a broken bone, each of which can easily cross $20,000 in expense because of the way hospitals, and health care in general, "upcharge" and "unbundle" their charges. Apparently, no one pays the listed price, so why all the confusion? I have no idea but is it possible that for tax purposes the difference can somehow be applied as a taxable loss as a business expense?

"Talk about what a tangled web we weave"

by blunderdog
on Tue, 02/08/2011 - 15:54
#944043

If all this info is accurate, and you're not happy with the "Obamacare" option, why not just skip the health-insurance and pay the fuckin' tax penalty?

Who in the world even wants health-insurance?

It's the ultimate definition of a sucker bet: insurance against shit you could *never* want to happen in the first place. If it pays off, you lose. If it doesn't, you lose.

I *know* some of these folks, and I'd predict: if something horrible happens to you and fucks your world, you're really not going to give a shit whether you can pay your bills for the emergency surgery.

by Dr. Sandi
on Tue, 02/08/2011 - 17:56
#944520

Once you get on the actuarial bad side of 55, the odds look a lot different.

You can stiff the hospital and all the various hangers-on for the first visit. But you're screwed if you ever have to go back there and don't have cash or credit card in your drooping paw.

by blunderdog
on Tue, 02/08/2011 - 18:09
#944556

Yes, I do actually appreciate that, which is why I say "IF" it looks like a bad deal, fuck it.

What I can't get over is listening to folks bitching about health-insurance costs on the one hand, taxes on the other hand, and outrageous health care expenses on the third hand. No one HAS TO take BP medicine. No one HAS TO have dialysis (or their kidneys replaced) after a decade of *not* taking BP medicine.

The money either has to come from somewhere or it doesn't--if it doesn't, just stop paying and die already. It's no one's fault that people get old and die, right? Your health is going to fail you no matter who you are or what you've done. If you don't want to pay for health-care, DON'T.

Just don't whine about it if you choose to pay. And don't blame government for the fact that you want the best possible care available and "money is no object" as soon as you reach that point, but it's a waste of your tax dollars as long as you feel ok.

Most people I know are completely infantile on this subject. It's no wonder no one's happy with our "policies."

by braveneweconomy
on Tue, 02/08/2011 - 12:55
#943379

Same here. I'm an independent contractor mid-40's and pay about $400/mo. for great coverage. I'm always perplexed by the people who scream about health care being too expensive.

by minus dog
on Tue, 02/08/2011 - 13:26
#943496

Sure, you can get insurance for $250/mo (assuming you can afford that - many cannot) but it doesn't do you any damn good for the sort of routine medical care someone my age actually uses. I typically get a huge cash discount, so my bill is essentially the same as if I were paying for the services with insurance... and without the monthly overhead.

Even at 250 a month, I'd be paying about 10x as much per year for medical and dental expenses. Even with the occasional serious injury every 3-4 years (about $3k a pop) I'm still coming out ahead.

Complaints about "freeloading" are going to fall on deaf ears - two words: Social Security.

This article is spot on; the system exists to fuck us and empty our pockets, why the hell would be participate in it?

by RKDS
on Tue, 02/08/2011 - 13:37
#943517

It would've been interesting for you to provide a salary for comparison, because to someone making $30K and taking home less than $2K per month, $400 right off the top actually _is_ expensive. And it's even worse if your employer doesn't offer coverage and you have to pay even more on the individual market.

by minus dog
on Tue, 02/08/2011 - 18:24
#944590

And, as people seem to keep forgetting, median individual income is somewhere around $26K

by HungrySeagull
on Tue, 02/08/2011 - 14:00
#943602

I know one retired dentist who endured 1200 dollars coverage per month for the wife. The moment the wife hit 65, medicare kicked in and he pockets the 1200 dollars per month.

HOORAY!

And if anything happens beyond what medicare pays, cash paid to billing all done.

by Mercury
on Tue, 02/08/2011 - 12:57
#943391

The acid test isn't whether or not your premium checks get cashed but whether or not you get what you need when you blow a gasket.

by tmosley
on Tue, 02/08/2011 - 13:15
#943456

Exactly. My company changed insurance this year and I went to the dentist for a regular checkup+x-rays. The insurance only covered half of the cost! This policy was the same price (to me) as the older one.

I would hate to see what happens if I were to actually have to go to the doctor or have some surgery.

by TheDriver
on Tue, 02/08/2011 - 13:40
#943556

I'm happy to fill you in on those details. As a 40 yo with reasonably priced coverage who had to face 2 unexpected, unrelated surgeries in as many years, I can tell you how bad things really are. I'll leave the country for future surgeries and pay cash. Even with airfare and lodging costs, it would be cheaper than having the work done in the US.

by HungrySeagull
on Tue, 02/08/2011 - 14:04
#943615

I had two insurance policies.

Both of them fought over a 16,000 dollar Ride in a MRI machine some time ago. They paid it. Then they fight over several surgeries I have had. They paid that too.

The moment Obamacare became law, I canceled both insurance companies and go to cash. If my doctor can fix a boo boo, great! Otherwise I make do.

I learned a month after cancelling for myself and spouse, our premiums would have gone up from about 870 a month to 1450 a month and some services cut back or disallowed.

Sorry. I am not putting money after a company that is cutting back.

Oh the small details about hospice, burial, cremations and all of that is already prepaid and arranged. One phone call does it all.

by baserunr
on Tue, 02/08/2011 - 14:07
#943631

See, here's a disconnect. Insurance is to cover the cost of expensive, unexpected-type events that have a small chance of occuring. If you are going to the Dentist for a "regular" check-up, that doesn't meet the criteria of what "insurance" is designed to cover. Many insurers have found a way to earn additional premium by expanding the boundaries of what they will "insure". That doesn't mean it is such a great deal for the insured; it just means the company can earn additional premium. If you work to keep the insurance for large, unlikley, and calamitious expenses, you'll probably find it very affordable. Pay cash for the rest.

by cxl9
on Tue, 02/08/2011 - 13:44
#943565

Agreed. I have been with Kaiser for years, and I can say that the service has been great. I have no complaints whatsoever with the medical treatment. I plan to stay with them for as long as I possibly can, at least until private health providers are eliminated in the United States and all of us are waiting in line down at the Post Office to get our health care.

by Thunder Dome
on Tue, 02/08/2011 - 12:58
#943394

I'm covering a family of four in the great state of Illinois--$20,000/yr not including dental.

by Threeggg
on Tue, 02/08/2011 - 15:32
#943955

Thunder you are doing better than me. (by $18 dollars) I pay $1718.00 for a Blue Cross Blue Shield Policy in Illinois. (it includes dental) That is for 3 people that are healthy.

I am looking into a major medical policy with a large deductable as I will pay for the regular medical expenses out of my pocket.

The medical sham put forth by Bamy raised all the prices. Now that they have the prices up over the rainbow they now want to repeal it. !

Prepare yourselves peeps as this running financial shit-train is pulling into the station.

[Mar 29, 2010] Will the GOP Remain the Party of No?

This is from The Myrtle Beach Sun:
DeMint, Graham let S.C. down on health care overhaul, by Isaac Bailey, The Myrtle Beach Sun: Two South Carolina legislators had the opportunity to shape the historic health care bill President Obama signed into law on Tuesday... Because the Senate version of the bill was going to be the foundation of the law, Sens. Lindsey Graham and Jim DeMint were our only two politicians who could have forced even more conservative ideas into the legislation. ... Neither did. Both shirked their responsibility to the state to walk lockstep with the GOP.
There was little reason to expect anything different from DeMint, who represents the party's Rush Limbaugh-wing. He didn't begin the debate saying we must find a way to bring down S.C.'s high percentage of the un- and underinsured. He didn't say we must find a way to stem costs that are spiraling out of control, bankrupting hard-working people for the sin of getting too sick. He didn't say the days of uninsured families having to leave coffee cans decorated with a sick loved one's photo on convenience store counters must end. He didn't say that if reform included strong tort reform so doctors would no longer feel the need to perform unnecessary tests that he would vote for it.
Instead, he said reform's defeat would be Obama's "Waterloo", that it would break the president. Only after his comments ignited a firestorm did DeMint propose a policy that most experts considered laughable. He was focused on politics, not people.
Sen. Graham began the debate differently. He knew if nothing changed, our health care system would eventually bankrupt us, which is why he initially supported the bipartisan Bennett-Wyden bill. ... But the proposal went nowhere fast. Instead of Graham engaging in the fight to incorporate the best parts of Wyden-Bennett - or any other effective plan - he fell in line with the rest of the GOP caucus.
He, too, became more concerned about his party's positioning for November than the people he was sent to Washington to represent...
The most vulnerable South Carolinians ... needed Graham and DeMint to lead. ... They didn't. Instead, they stood for the petty and ignored the real needs of the people. History won't forget. And neither should we.

And, from the local paper this morning:

Move past 'repeal, replace', Editorial, Register Guard: Republicans are preparing to march into the 2010 election under the dubious banner of "Repeal and replace!"
It's a losing strategy, one that GOP lawmakers should rethink before venturing too far down that road. The health care reform bill has been signed into law. ... The Republicans should turn the page on health care if they want to shed the "party of no" label that served both the GOP and nation poorly in the debate over health reform.
That doesn't mean that House Minority Leader John Boehner and other Republican leaders should publicly embrace Obamacare. That's unrealistic; their philosophical differences with Democrats on reform are too deep and broad, and Republicans resentment over President Obama's historic achievement precludes even the pretense of a political truce.
But Republicans face long odds in any attempt to repeal and replace health care reform, and they know it. ... As Sen. Jon Kyl, R-Ariz., acknowledged, repeal "is not realistic because Barack Obama would veto the bill and we don't have the votes to override it."
For Republicans such as Boehner, Kyl and DeMint, "repeal and replace" is an election strategy and not a practical legislative goal. ...
Repeal-and-replace Republicans eventually must face the difficult task of explaining why their apocalyptic predictions - everything from the death panels to the dismantling of democracy - didn't come true. In the months and years to come, many Americans, even those skeptical about the reform effort, will come to see the scare tactics as hyperbolic depictions of a bill whose moderate approach incorporated many Republican ideas.
Republicans have just suffered a devastating legislative defeat, and they are entitled to nurse their wounds. But the GOP's political aspirations - and the nation's interests - would be best served by full engagement on the many critical issues facing Congress, from financial regulatory reform to immigration to unemployment. ... Republicans remain fixated on their loss on health reform - so much so that some, including Sen. John McCain, R-Ariz., have publicly ruled out any bipartisan cooperation for the remainder of the current session.
The American people need - and deserve - a legislative process in which both parties are engaged and bring competing views to the table. By clinging to the cold corpse of the health care debate, Republicans will miss an opportunity to express a clear, compelling vision on other issues - a vision that could do far more to sway voters to their side this fall than continuing to flail away over health care. ...
While there is still time, Republicans should repeal and replace their catchphrase, and substitute another that bodes better for their party's future.

There's an inconsistency between free market ideology and the need for reform in areas like health care and financial services. One of the first steps in reforming the system is to acknowledge that the market won't take care of the problems itself. Once that is acknowledged, i.e. that regulation is needed to fix these market failures, the only question is whether that regulation will be of the "market-based" variety or by edict (e.g. this is the difference between system of tradable carbon permits that allow least cost carbon reduction strategies to emerge and a government set emission limit for each industry which generally does not achieve ca4rbon reductions at least cost).

With Democrats mostly opposed to old fashioned edict style regulation -- with their willingness to embrace market-based solutions to regulatory issues -- and with Republicans unwilling to embrace anything that Democrats propose, there is little ground left for those Republicans who are willing to admit that markets sometimes fail to stand upon. Democrats have taken the middle ground -- market based regulation -- from Republicans. This leaves Republicans with a choice of going along and compromising (and thereby embracing proposals they have made in the past, e.g. the health care bill looks an awful lot like the health care program Romney put in place in Massachusetts), or standing in opposition simply because it is a Democratic proposal. The choice they've made, standing in opposition to everything, is a losing strategy that allows policy to be shaped entirely be the other side. It will be interesting to see if a fissure develops within the Republican Party over this.

Will Republicans be able to share the market-based regulatory ground Democrats have taken away? There are already signs that Republicans will work with Democrats on financial reform, but there were early signs of a bi-partisan effort on health care as well, so we'll see how this plays out. I think people are fed up with banks and want something to be done, and Republican attempts to block legislation won't play well with the public at all. So I expect the coalition of no to be broken -- some legislators will see that they cannot continue just saying no and expect public support -- but not without big fights within the Republican Party between the extremists and the centrists. If Republicans do move in this direction, and it's more likely they'll do so on financial reform than on climate change legislation, you'll see an attempt to reclaim these policies as Republican (here's a great example: Health Care Reform--A Republican Idea?). And given the administration's centrist tendencies, in many cases they'll have a pretty good argument.

Posted by Mark Thoma on Saturday, March 27, 2010 at 10:34 AM in Economics, Financial System, Health Care, Politics, Regulation Reblog Permalink Comments (32)

Comments

roger said...

MT, you write about the Dems "willingness to embrace market-based solutions to regulatory issues" - I'd read that a little differently: with the Dems "unwillingness to embrace regulatory solutions to market-based problems."

That, I think, is a more accurate index of the Democratic party's conservatism.

howard said...

we can only hope that the gop will go all-in on repeal....

jrossi said...

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

Get to work on this, politicians of America.

OhNoNotAgain:

The big question is: are the Medicaid rates for specialists enough for them to make a profit and cover their costs ? If so, then I think these specialists are going to find themselves in a lot of trouble if they keep up the practice of refusing to see patients because the payments aren't as high as they want them to be.

jrossi:

That is a big question. Profit is total revenue minus total expenses. What you're really asking is whether the marginal cost of seeing a Medicaid pt is greater than the marginal revenue you get from seeing the pt. Well, it depends on the practice's variable cost structure, doesn't it?
Another interesting question is opportunity cost. If you can see a private pt at $200 and a Medicaid pt at $75, the choice is easy, if you can pick and choose.
Will the specialists be in a lot of trouble? Again, it depends. If I send the ENT 9 paying pts for every Medicaid one, he risks losing a lot of money by pissing me off and refusing to see my Medicaid pt. If I send 2 paying pts for every 8 Medicaiders, well, he might not care for my business.
The devil is in the details in HC reform.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

[I know, I know and this is quite important and especially worrisome since there are supposed to be further limits to physician payments to come and the limits are to be selective in terms of area of practice.]

Hal:

The GOP seems headless. One would think McCain would be the leader, but he is so weak and desperate he needs Palin to help him keep his senate seat. When Palin is the GOP's not so secret weapon you can be pretty sure the party is headless, or better, brainless. What is frightening is that brainless might win lots of votes in 2012 if Americans are still angry and uninformed.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag....

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

March 25, 2010

More Doctors Giving Up Private Practices
By GARDINER HARRIS

The delivery of medical care is changing as more young physicians take jobs with heath systems and older doctors sell their practices to those same systems.

[Also, the nature of what a community doctor is and how much leeway such a doctor may have is changing and seemingly quickly.]

alan :

There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system. For example, I went to doctor to get finger stitched, was told I needed a surgeon and had to go to ER. All I got was 5 stitches! Maybe the primaries and nurse practitioners will have to get on with doing real care instead of referring, and maybe we'll have to figure out how to get the gun-for-hire lawyers to back off.

jrossi :

That's weird Alan. This family doc sews people up all the time, and so does my NP. You must live in the East or in a big city.

jrossi :

Anne, Independent family docs have been a dying breed for years, but now it's hitting the specialists--and quick. I don't know if it's good or bad. Interesting times.

Fred C. Dobbs:

I wonder, is there any other reason for this than specialists getting much better salaries?

It is true, apparently, that doctors are 'practicing differently' these days.

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

NYT - March 25, 2010
More Doctors Giving Up Private Practices
By GARDINER HARRIS
WASHINGTON - A quiet revolution is transforming how medical care is delivered in this country, and it has very little to do with the sweeping health care legislation that President Obama just signed into law.

But it could have a big impact on that law's chances for success.

Traditionally, American medicine has been largely a cottage industry. Most doctors cared for patients in small, privately owned clinics - sometimes in rooms adjoining their homes.

But an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems. And a growing number of older doctors - facing rising costs and fearing they will not be able to recruit junior partners - are selling their practices and moving into salaried jobs, too. ...

jrossi:

It's the money, Fred. If PCPs could make a reasonable living we would not group up much. Actually, a small single-specialty group is fine, mainly because you can share on-call and overhead, plus a lot of us like a small group--two or three heads are better than one. But most docs, myself included, would avoid multi-specialty groups, where PCPs are low men on the totem pole, and hospital or health system owned groups, where a@@holes in business suits call the shots. Most docs like to be independent. But you can't make much of a living doing this, so we are forced to group up. There's a recent post at Kevinmd about a doc worried about cuts in Medicare putting him out of business (he's an internist so he should be OK at least temporarily with the 10% increase), but the details of the doc's practice finances are interesting. Revenue 800k, Costs 720k, take home 80k. He shoulda gone to nursing school, probably would get paid more.

Fred C. Dobbs:

I think it's interesting that doc's like to be businessmen, get the revenues, don't like the costs, complain about the net. Forget nursing; go be a (salaried!) hospitalist. On the other hand, you guys are heroes & life-savers. Deal with it!

You want $$$, go be investors.

Zephyr:

The healthcare system is being choked by the pressures of the insurance system. Insurance is the biggest problem with our healthcare system. We need to remove the insurance bureaucracy from the healthcare dollar. This applies to government insurance and private insurance.

We need publicly funded clinics and hospitals available equally to all.

We have public roads, public defense, public schools...
...why not public healthcare?

Fred C. Dobbs:

Just 4 years ago, Mitt Romney was getting along wonderfully with the Democrat-controlled MA legislature, famously establishing universal health care (which was good enough to become the model for the US plan). Things were looking up for him and the Republicans, sort of. Then the election campaign of 2008 happened and the Republicans soiled themselves. The question has to be, can they swallow their pride, clean themselves up, and return to rational political discourse? The country sorely needs to have two functional parties, for balance if nothing else. It's not looking good, yet.

Fred C. Dobbs:

'Things were looking up for him and the Republicans, sort of': aside from a furious
urgency to get past the Bush Jr years a.s.a.p.

anne:

Alan:

"There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system."

The effect of malpractice concerns has been repeatedly studied and found to have a minimal effect on health care cost. A sense of this is that by the beginning of 2005, there were already a majority of states with malpractice suit limits in effect and the difference has been minimal if any. Nonetheless, there is a sense that malpractice makes a difference in costs even among doctors even in states with the strictest limits such a Texas. This would seem quite wrong.

Fred C. Dobbs:

It's arguably effective that doctors would have us believe that they need high pay to cover their
malpractice premiums, even if it's only anecdotal.

anne:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

June 1, 2009

The Cost Conundrum: What a Texas town can teach us about health care.
By Atul Gawande

"It's malpractice," a family physician who had practiced here for thirty-three years said.

"McAllen is legal hell," the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn't lawsuits go down?

"Practically to zero," the cardiologist admitted....

Fred C. Dobbs:

Interesting , but as the article says:

'McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami-which has much higher labor and living costs-spends more per person on health care.'

What does this 'teach us about health care'?
Don't do it like they do it in McAllen TX.

Fred C. Dobbs:

Even more interesting, the article says:

'The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine.' ...

I believe I have read that this has to do with physician-entrepreneurs 'providing' (selling?) diagnostic testing to their patients. Very profitably too. Personally, I think testing is a great idea, when done ethically & cost-effectively.

Fred C. Dobbs:

By the way, many doctors think
'the world' of Atul Gawande, MD.
http://gawande.com/about
Brigham and Women's Hospital
Department of Surgery
gawande@gawande.com,
etc.

Reality Bites:

The cap instituted in Texas is not the malpractice reform that was proposed and rejected. Notice that only pain and suffering is capped at $250,000. A doctor could still get sued for millions if he fails to test for an obscure ailment that eventually leads to a loss of function or life. Thus the need to practice defensive medicine.

Republicans aren't on board on this bill. Their proposals voiced during the "debate" with Obama were rejected. There's no reason why they should lend support to a bill they believe will be very harmful to the country and end up raising health care costs.

ken melvin said...

If there really was a god, those who keep on yapping about malpractice would be among those who got their brains fried and the letter of apology cause see MO has a $250k cap.

beezer said...

The 800 lb gorilla in the room is the doctors, or lack thereof.

We don't graduate enough physicians because it's pretty much financially out of reach for most of those smart and talented enough to compete. Too few of anything is going to raise labor rates.

Also, we've turned physicians into businesspeople first. Got to make that real big "nut." Not really the right focus for medical care overall, and certainly not for producing affordable care specifically.

Too many doctors today got there in order to become wealthy. And as long as that is the primary motivation, health care will always be far too expensive.

Open up education by subsidizing medical education so all the bright young ones can compete, in return for guaranteed salaries. We'll get a stronger corps of physicians overall, as well as physicians who have the right motivation to begin with.

History:

Per Uwe Reinhardt, who knows about these things, US medical costs are too high because we pay too much for things. (Not that McAllen-style overuse isn't a problem also). The things are:
1) Medical bureaucracy, i.e. insurance companies.
2) Drugs
3) Doctors, who are paid about twice what they are in the rest of the world relative to prevailing incomes.

Our gross overpayment per year (compared to other advanced countries) is about $1T/yr,
split $300B, $300B, $400B.

We're discussing point three. The main reason (along with what beezer correctly said) for this situation is that Lyndon Johnson bribed the AMA into letting him pass Medicare. The bribe took the form of allowing arbitrary pricing for new procedures, under the rubric "usual, customary, and reasonable". In this scenario a procedure might cost $50 and a somewhat improved one $5000. I actually saw one instance of this apparently absurdly exaggerated increase cited; although I'm too lazy to look it up.

The doctors who are highly paid are the ones who do procedures. Hence, a lot of procedures.

Cutting procedure reimbursement rates is indispensable to cutting costs. The solutions to monopoly-based price increases are: 1) regulation, or 2) monopony; you take our business because there is no other.

[Mar 29, 2010] Booming business helps patients navigate medicine - The Denver Post

By MIKE STOBBE AP Medical Writer Article Launched: 07/24/2008 12:21:20 PM MDT NORCROSS, Ga.-After three surgeries, Judy Sherer still had chronic pain in her left shoulder. She'd lost faith in her doctors, and in despair tried a new health benefit offered by her employer.

The service, Health Advocate, is a call-in center that helps customers find the right doctor, haggle over insurance coverage and manage other medical system headaches.

An advocate helped Sherer find a new surgeon-one who found metal shavings left in her shoulder by a previous doctor. The advocate also negotiated the charge for her physical therapy down to $40 per visit from the $200 she was told initially.

"It saved me a ton of money," said Sherer, 63, of Norcross, Ga. "I'm very, very pleased."

Health Advocate is one of a growing number of U.S. companies offering some form of advocacy services to medical consumers. Revolution Health-the Web-based medical consumer services company overseen by AOL co-founder Steve Case-has been considering getting into the same business.

"It's a really interesting industry that's just taking off," said Carol Fischer, a spokeswoman for Pennsylvania-based Health Advocate, a 12 million-member organization.

Currently, the health advocacy business is an industry with about $50 million to $75 million in annual revenue but only about a dozen companies of any significant size, said Richard Rakowski of Intersection LLC, a Connecticut-based investment and development firm that has researched the field.

But those numbers have grown from a few years ago, and it may be on track to become a $1 billion industry based on the demand for the service, said Rakowski, the firm's principal.

The field is blossoming in the wake of cutbacks in corporate health benefits, an overhaul of Medicare and other changes that have forced medical consumers to shop more for medical care.

More than ever, people need help negotiating the medical system, said Jessica Greene, a University of Oregon health policy analyst.

"We're asking consumers to make more complicated decisions, but the numeracy and health literacy skills of many consumers are not at the level needed to handle this new responsibility," Greene said.

Though some consumers are savvy enough to beat a billing overcharge or probe doctors' litigation histories, they don't have the time for such labors, experts said.

Indeed, the largest customers of health advocacy services are companies, not individuals. "The employers are interested because it means their employees are not on the phone taking care of doctor's visits" during work hours, Fischer said.

The companies grouped into the health advocacy business range from small regional firms operating out of home offices to companies with national call centers the size of football fields. No one seems to have an exact count, but Flagship Global Health, Care Counsel and Enhanced Care Solutions are among the more visible names.

Health Advocate claims to be the largest. Founded in 2001, it now has more than 3,500 companies, unions and other organizations as clients, including Johnson & Johnson, American Express and The Home Depot Inc.

Altogether, about 2.6 million employees, or members, are signed up with Health Advocate. But the number who can use it is actually higher: Members can share the call-in number with spouses, children, parents and parents-in-law-including elderly kin who need help picking a Medicare prescription drug plan, finding a nursing home or arranging transportation for health care. With all relatives added in, Health Advocate's membership as roughly 12 million, Fischer said.

About 180 advocates staff Health Advocate's call center in suburban Philadelphia. It's usually registered nurses who talk to the patients, and each patient gets an advocate who stays with the case and is the recurring contact. The staff also includes behind-the-scenes workers who help with insurance claims and other administrative questions.

"I'd say 80 percent of (our) people call Health Advocate because they have trouble with billing," said Andrew May, a human resources vice president for Wells Real Estate Funds, the Georgia-based company that employs Sherer.

Initially, May said, he doubted Wells employees would use Health Advocate, thinking they would instead continue to come down to human resources for help rather than turn to a 1-800 number.

But some of Wells' 400 employees started using it and having great experiences, he said. Company executives appreciated the help, calling the $5,700-a-year cost a good deal.

"We're not billing specialists. We're not registered nurses. To have that resource is much more powerful-it gets to the bottom of things quicker," said Susanna Johnson, a Wells human resources manager.

Health Advocate in May began to sell its services straight to individuals, as a $365-a-year service.

Some other companies have always focused on individuals, especially rich ones.

One example is $10,000-a-year PinnacleCare, founded in 2002 by John Hutchins, who created a concierge-like service at the Cleveland Clinic. He later used his connections to build a national network of doctors for his private health advisory start-up.

The Baltimore-based company is essentially a club for millionaires and billionaires that puts nurses and social workers in touch with members. Not only will they help members find top-level care, they will get them moved to the head of the line. PinnacleCare advisers will even meet the patient at a doctor's office or hospital.

PinnacleCare has about 1,700 member-families. One satisfied customer is Kirk Posmantur, 45, the founder and chairman of Axcess Luxury & Lifestyle. His Atlanta-based company markets handmade watches, private jets and other luxury items to the affluent.

"It's a no-brainer for those who've got net worth of $5 million or more," he said. "You've got people who advise you on your taxes. You've got people who advise you on how to manage your money. But what's more important than your health?"

Not every health advocacy group is a for-profit business.

The Patient Advocate Foundation provides free help to people with chronic, debilitating and life-threatening conditions. Founded in 1996, the Virginia-based organization has 113 employees and an annual budget of about $8.5 million. It handled nearly 45,000 cases in 2007-most of them cancer patients.

The organization's founders initially expected many clients to be uninsured. As it turns out, about 80 percent have at least some health insurance but are dealing with pre-approval authorizations, medical debt from incomplete coverage or other problems, said Nancy Davenport-Ennis, the group's chief executive and co-founder.

Companies like PinnacleCare are a blessing "for those consumers that can afford to have a boutique service," she said.

She wishes, however, that companies would provide more pro bono service. "The concern is those that need help and can't afford something like that," Davenport-Ennis said.