More of Obama's slippery slope.

[Bill Glasheen]

I don't have much to argue about, Ian.

And we have to stop wasting our healthcare dollars. The culture of medicine here is the largest problem. I strongly encourage everyone to read this:

http://www.newyorker.com/reporting/2009 ... ct_gawande

This is the study I referred to above, that was done by my company (with the pre-merger name). Funny that, no?

- Bill

[IJ]

Few things:

1) Just because people come to the USA for top healthcare, doesn't automatically mean that the quality they seek is a result of our unique nonsystem. That's top medical research they're looking for, and it is derived from a lot of factors including sponsored research, the ability of pharma to make cash on new drugs, etc. Having a government option or getting rid of private insurance period does not necessarily mean that all changes and people start going to Romania for liver transplants.

2) It's one thing to say it'd be easy to save money by getting all the illegals out, but it isn't necessarily politically, or practically, doable. Some of them are, you know, hiding. It takes lots of cash to find and deport them. I do believe a state has the right to refuse to fund impoverished illegals from their neighbors, but don't expect that to be an "ethical" decision. "Get lost and go die" is not something we are good at saying in the USA. As a start, I think it'd be reasonable to limit the more costly things we do.

3) we gotta get meaner on our own people. All those entitlements? Making people entitled. We are going into debt financing golden years. On what logic? Social Security was intended for people who were imminent--it was pegged to the average lifespan of 65! By those rules we would be giving it at 75 now. People didn't retire; they worked until they couldn't or died. It'd be nice if we could all pay for granny's extended down time, but now the fact is that all the boomers need more than their kids have and they should consider extending their work life. It's good for them, too--see the Japanese example. If medicine / societal changes allow us to extend the infirm period of time when people can't work to the point where we can't afford their care, well--somethings gotta change.

I admitted a lovely 100 year old lady today. Do we seriously think that someone can work 47 and retire 35 years? Hard decisions are coming.... our USA will become a poor debt option and our interest rates will shoot up, borrowing will drop, spending will go way down, and we'll be... I dunno, Greece.

[Jason Rees]

3) we gotta get meaner on our own people. All those entitlements? Making people entitled. We are going into debt financing golden years. On what logic? Social Security was intended for people who were imminent--it was pegged to the average lifespan of 65! By those rules we would be giving it at 75 now. People didn't retire; they worked until they couldn't or died. It'd be nice if we could all pay for granny's extended down time, but now the fact is that all the boomers need more than their kids have and they should consider extending their work life. It's good for them, too--see the Japanese example. If medicine / societal changes allow us to extend the infirm period of time when people can't work to the point where we can't afford their care, well--somethings gotta change.

I think the world just stopped turning. I agree with IJ.

[cxt]

IJ

Can't say that I disagree all that much.

You are of course correct that there are many factors that make the USA the location of choice....but just like there are many factors that result in say someone being the best athlete in a sport...they are still the best

I do however disagree.....only in part...with the "we gotta get meaner on own people"....not that you're not correct....just that if we "gotta get meaner" then I would feel better if we "got meaner" in other areas first.....or perhaps equally mean in all areas.

In terms of total life span and being infirm etc---again, no real disagreement......but a whole raft of things have been pegged to assumptions of lifespan---such as lifetime appointment to the Supreme Court for example----when that rule was established nobody had an inkling that someone could serve 30 years on the Court----or as many years as they will be able to serve in the near future due to new advances.
Its not that you're wrong....far from it....its that the ramifications might well require a host of serious changes that go far beyond healthcare.

Also...by way of food for thought.....not argument

Consider ones old age not as the current mode of being closer to the grave so you should get less healthcare but rather as people, that unlike the young folks whom hav epaid little to nothing, have already paid 40 years worth of payments into the system---essentially paying for the care of the generation prior to them.

Not sure that its all that ethical to now expect them to not get back what they already sank into the system---the more so since their efforts paid for others
I bust my hump for 45 years to pay for the prior generation and now that its my turn its "sorry man, we got draw the line somewhere."

Or think of it like this----you buy a new car and for 5 years you make the payments on time and in full----you bring your last payment to the dealer and he tells you that he sold the car to a 16 year old kid--because.."he will get more use out of it than an older person would......thanks for the all the payments.....but please hand over the keys"

Like I said......not argueing.....many things need to change......but I see a real clash of conflicting ethical imparitives coming......there may not be a good choice/s....just the least bad option.

[IJ]

People are taking more out of SS than they put in. That's because the boomers are many people who financed a smaller generation of retirees. Now, we've got a smaller generation of people financing a larger generation of retirees. If fair is fair, we cut their bennies right away.

I'm fine with limiting SCOTUS appointments too if all concur. But it's unrelated--they're lifetime to ensure wisdom and to keep fashion from influencing the Constitution and that has nothing to do with planning lifelong retirements for people who were expected to live a few years and now should work longer before reaching the state we used to associate with age 65. Heck many more people were plain DEAD by 65! It's like the viagra effect article from Bill. Law wasn't intended to finance a widower for a million years. Old hubbies aren't a retirement investment.

[Bill Glasheen]

There are several issues here.

First... The biggest reason not to let the damn government into this mess is being argued above. The tradition of government is to redistribute wealth. They rob Peter to pay Paul.

If the government set Social Security money aside for me, then I want that money if I live long enough. I don't want them squandering the money away on something else today and then praying that money is going to be there when the next generation works. Pardon me for pointing out the obvious, but this is no different than chain letters and Ponzi schemes. We throw citizens away for doing this but it's legal for the government to do so? Sorry...

The determinant of what should and shouldn't be covered should be a contract between the insurer and the insured, and not something dictated to me by a government. Sorry, liberals, but you can take your Nazi Government health plan and shove it.

• Because I am a boomer, I cannot rely on Social Security to be there when I retire. And yet you want to take more away? I don't think so... I need to save for my own retirement because the government f-ed up and it isn't going to be there. You don't get to steal from me twice.
• Because I am a boomer, I cannot rely on Medicare to be there when I retire. And yet you want to take more away? I don't think so... I need to buy my own Medicare extended policy (or even my own full service policy) for my own retirement because the government f-ed up and it isn't going to be there. You don't get to steal from me twice.

So take your government-run health system and shove it. I sacrificed all my life. I didn't get to go buy nice things because I was planning for my future. Boo hoo if my neighbor didn't. Not my problem.

Also...

Ian's language isn't right. It's not being meaner. It's RATIONING. Call it for what it is. We ration care so we pay for what's evidence-based and what will give us the greatest return on our investment in insurance policy. No, that doesn't mean we tell granny to take a hike because junior needs his immunizations. Granny gets to dip into the insurance reserves too - if there is a return on that medical care. If not,. then I have no problem with the insurance company (by contract) or Medicare (by their own medical policy) or her doctors (by medical guidelines) saying they won't do such-and-such.

One final thing. I have no problem with the retirement age being raised. But let's get the liberals out and fight against ageism. Don't tell me it doesn't happen either, because it does. And don't tell me middle-aged white males don't get discriminated against, because they do. They do BECAUSE they aren't the minority and so are the first booted out the door during downsizing. And how do I know? Been there, done that. Last time I was sent to a placement agency, virtually 100% of the people laid off (from myriad industries) were middle-aged to older white males. Not a protected class, so the first to go. That's... DISCRIMINATION!

Yes, let me work longer. Make everyone work longer. Then the system won't break down. BUT.... LET us work longer, thank you very much. You don't have to pay us as much if we slow down a bit, but then you should pay the older workers for stability, knowledge, and wisdom.

Wow, liberals, what goes around comes around.

Off of soap box.

- Bill

[Gene DeMambro]

Oh for Pete's sake, Bill. Enough with the "redistribution of wealth" bull and the "Nazi" health plan idiocy. That makes you no better than that moron Barney Frank shouted down at his town meeting. But I know that isn't true about you. Want decent roads, a kick ass military, clean air and water, decent schools (I dare you to provide equal opportunity without them), police patroling the streets and - yes - quality hospitals, then all that costs money. Sorry if you don't think so, but the free market isn't the solution to everything. Look at practically every government regulation - state or federal - and behind it is a company that at some point tried to sacrifice safety of someone or something in the name of profit. The only wrong in making profit is when one sacrifices principles to get there.

"The purpose of government in a capitalistic economy is to step in at the edges when the free market fails."

"So design a health care system around that. The current one isn't working."

Still waiting for an answer on this one.

Gene

[Gene DeMambro]

I always get a kick out of it when people compare health care to cars. Maybe the comparison is actually a good one. At least if you don't have a car you can take the train or the bus to get where you are going. You know, public transportation as an option. And I don't see car companies going bankrupt because of this public option....

Gene

[Bill Glasheen]

Oh for Pete's sake, Bill. Enough with the "redistribution of wealth" bull and the "Nazi" health plan idiocy.

Sorry, Gene, but I call it like I see it. Obama has been redistributing wealth and mortgaging the future of my kids since he came into office. Maybe if you don't have kids, the future means nothing. But I have flesh (and blood) in the game. So I'm all over the socialist plans.

That makes you no better than that moron Barney Frank shouted down at his town meeting. But I know that isn't true about you. Want decent roads, a kick ass military, clean air and water, decent schools (I dare you to provide equal opportunity without them), police patroling the streets and - yes - quality hospitals

Bzzzzzzzztttttttt!!!

What do quality hospitals have to do with the government? All the good ones around me are private. The statistics prove it. Go figure...

I always get a kick out of it when people compare health care to cars. Etc., etc.

That's a 15-year-old argument, Gene. It's one that doctors used against us when we first started doing economic and process quality profiling of MDs and hospitals. You can't compare us to making widgets... I don't do cookbook medicine... We aren't all about Consumer Reports...

And now folks are copying what we did. And publishing the results so consumers can see. Who would have guessed it?

Better yet... The good MDs are getting into the act, supplying methodologies and codifying evidence-based care. And they're buying into the concept that medical care can be quantified, risk-adjusted, and evaluated on multiple dimensions.

Just like cars!

Please read The New Yorker article above that Ian cited. I worked for both of the health information companies that were sources of the analyses. Because of new methodologies, we now know why things go wrong. And explanations aren't that complicated. For instance... If MDs in the region have a conflict of interest (invest in outfits that perform ancillary services), then overutilization happens. And quality doesn't improve with it.

It's as simple as explaining why Honda thrives while building cars in this country, and GM goes bankrupt. Some can do it better AND cheaper, and satisfy the customer while they're at it.

"So design a health care system around that. The current one isn't working."

Still waiting for an answer on this one.

Well let's start with rule number 1:

>> CHANGE (for change's sake) is not equal to better.

- Bill

[Gene DeMambro]

You get no argument from me on quality. Bill. Want to stop unnecessary lawsuits? Crack down on providers and hospitals that aren't cutting it quality-wise. Hit them in their pocketbook, and then maybe they'll find religion.

[Bill Glasheen]

Hit them in their pocketbook, and then maybe they'll find religion.

Actually that isn't necessarily true. In six sigma, you measure variability, or variance from a standard. But if those data can be used against you by trial attorneys, then that kind of measurement is less likely to happen.

Mistakes happen, and no therapy is without potential downsides. Tort reform can make quality assessment more open, and speed up the learning process.

- Bill

[Gene DeMambro]

That New Yorker article has lessons in it for everyone. Since I read it at Bill's suggestion, I will ask him what conclusions the article states he agrees with, and which ones he doesn't.

Gene

[Bill Glasheen]

McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

The lessons are not that complicated.

1) Overuse, underuse, and misuse of health care services = bad medicine.

2) When there are perverse incentives, bad medicine happens.

3) Supply-induced demand happens.

4) Coordination and continuity of care is a good thing.

- Bill

[IJ]

Bill is prone to hyperbole. I have the same problem. It's cool. This isn't "Nazi" health, of course, because that would mean we would be gassing people who can't pay their premiums. Har har; that is NOT the right way to discuss this issue. All this stuff about death panels and the reality is the law states doctors should be able to talk to patients about end of life care without doing it for free, and the patients' wishes should be followed and we should measure outcomes to ensure they're measured. That's the opposite of Nazi. It reminds me of the Daily Show when Obama is called Hitler and we wonder, isn't he the opposite, and they show us a guy who's hairy all over his face except the upper lip, that's the real opposite Hitler

Bill, I wouldn't take your benefits that you paid for all your life, HOWEVER, I'm sure you would agree you should get back what you gave, and if a group financed a smaller generations retirement they shouldn't expect to have a smaller group finance theirs for a longer duration. We should return what was taken and if some's been screwed up we may all have to pitch in for the kids' sake.

As for free market reigning in insurance, wow, what a freaking disaster that would be. We already have problems of crappy choice with work related insurance and anyone in the individual market will be destroyed if they have so much as sinusitis. It's as fair as OB malpractice insurance in bad states. I DON'T believe that anyone should be able to buy into insurance with preexisting conditions (as I recently saw Franken suggesting, for example) UNLESS they're required to carry insurance. All you get otherwise is people not paying into the system until they get sick then voila let's buy some insurance. Whatever! Criminal!

Right now, my Nazi suggestion is this:

Any doctor who won't participate in monitoring of outcomes and processes
Any doctor who won't relinquish conflict of interest stakes such as self referral to MRI and kickbacks
Any doctor who won't participate in evidence and guideline based directives for care, (with exceptions for truly unusual clinical circumstances)
Any doctor who won't participate in understanding regional differences in cost and quality and in upgrading the care in high cost areas....

Shoot them all. I do NOT expect that my state supported education, my professional oaths, my clinical privileges, my patients exist so I can make crazy bank and have the freedom to always "autonomously" practice "individualized medicine" divorced from rigorous science and study and quality/cost considerations. Only petty tyrants with God complexes say stuff like that. Lead, follow, or get the F out of the way, people. The AMA should ban the absolutely embarrassing practices mentioned in Gawande article superSTAT and make participating in the quality movement a professional obligation.

[Bill Glasheen]

Mostly we're in agreement, Heil Hitler!

As for free market reigning in insurance, wow, what a freaking disaster that would be.

It doesn't; that's what the state BOI does. They do things like require an insurance company to maintain a reserve, execute their contractual obligations, etc. States have the right to exercise even more control. For instance what happened in McAllen, Texas is illegal in the Commonwealth of Virginia. An MD cannot refer to an MRI facility that he has financial interest in. (I was part of a panel of industry representatives that helped put this law in practice.)

Bill, I wouldn't take your benefits that you paid for all your life, HOWEVER, I'm sure you would agree you should get back what you gave, and if a group financed a smaller generations retirement they shouldn't expect to have a smaller group finance theirs for a longer duration. We should return what was taken and if some's been screwed up we may all have to pitch in for the kids' sake.

The problem started with the federal government Ponzi scheme. We get put in jail if we do bookkeeping that way.



The Feds however call it business as usual. That's why I don't want them in the business. They already messed up.

And I don't want to pay for yet another Federal program with my tax dollars after already having to pay into a Social Security system that won't benefit me and a Medicare system that won't benefit me and having to save for my retirement and a supplemental insurance policy to cover the care I'm not going to get because either it will be inadequate (due to inadequate funds) or they'll decide I'm "too rich" and can buy my own insurance anyhow. Once again... The BOI would never tolerate that crap, but the Federal government can get away with it. Just like the state got all over BCBS bargaining better prices for hospital stays but didn't pass the savings on to the policyholders, and yet it's perfectly legal for the Federal government to do that.

I've seen too much, and it scares the sheet out of me. I don't want to see more.

We already have problems of crappy choice with work related insurance and anyone in the individual market will be destroyed if they have so much as sinusitis.

I agree up to a point. We get pretty damn good medical care with work-related insurance. But as I suggested earlier, we need purchasing cooperatives (as Enthoven suggested about two decades ago and Germany implements) to protect the individual and small business market.

... I recently saw Franken suggesting ...

That's what Minnesotans get when they elect a WWF wrestler for governor and a comedian for congressman. One wonders what the hell those Scandanavians are partying with during those long and boring winters up there. Either that or they have one hell of a sense of humor, and the joke's on us.





- Bill