Price controls coming for health care

Limited? Scurvy is ok but not starvation? Sixth grade and tyou're out? Or tenth but you can read at a sixth grade level?

Novice: "Once I understood fully that Steve's positon is that his sole criterion for quality is mortality and that his interpretation of data leads him to believe that a more socialized system will lead to better mortality stats at a lower cost, I felt no need for further discussion."

It's not "my" interpretation of the data, novice; it's pretty much universally accepted. If anybody were to built a healthcare system from scratch, they would not build ours.

The fact is, throughout the world, more socialized healthcare systems consistently deliver better results at a far lower cost. It's not an "opinion"; it's an objective fact, and it has been proved again and again by the Congressional Research Service, the World Health Organization, the Urban League, and most recently The Commonwealth Fund:

"Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives."

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf

It's not random; it's fact-based.

You can believe whatever you want. Lots of people do. It's called fantasy.

I don't rule out possibility that more socialized system will improve mortality rate; however, I think there might be more factors at play. Correlation does not equal causation. Bur again, mortality rate is not my measure of quality of healthcare system. In my ideal world we have system that provides universal care while also providing market incentives for innovation. I envision my own taxes and personal healtchare costs increasing under such a system and have no problem with that.

Look people Steve is right --- about everything-- every one else is wrong.
Hahahahahahahahahahahahaahahahahahahahahah stomach hurts from lmfao

PS my typos and grammar are getting worse these days bc I am replying from handheld touchscreen device and am not adept at the interface so I cannot proof anything before I send it. Sorry - painful to read.

Novice: "Correlation does not equal causation."

No, not necessarily. But it doesn't rule out causation, either, and 100% of all studies say the same thing. So, pretty much it's causation.

And then there's Brooksie! What a silly billy you're being!

Brooksie's Financial Wisdom: "Treasuries are positively convex so they will NOT act in the opposite way as MBS which are negatively convex."

Definition of positive convexity: "The price-yield curve will increase as yield decreases, and vice versa. Therefore, as market yields decrease, the duration increases (and vice versa)."

Negative convexity: "as market yields decrease, duration decreases as well."

That's not opposite, is it Brooksie?

http://www.investopedia.com/university/advancedbond/advancedbond6.asp#axzz2Fb3sn2Ua

WHAT A MAROON!

there is really no question as to whether or not the health care system in the us underperforms at many levels. it's not bad, but increasingly worse, if you are upper middle class or higher. if money is no issue then it's still quite good, but given how expensive and onerous medical school is for the average returns one has to wonder how much longer that will be true.

I think we all agree system is far from ideal; area of interest for me is how to fix availability and affordabilityty while improving quality.

But my point is that it UNDERperforms compared to other countries with more socialistic systems. And the arguments involving the free market leading to innovation in medical advances are superficial at best. Big pharma is an international phenomenon and has been for decades. I recently read about a scientist who believes she has discovered a new use for a drug but can't get clinical trials financed because the drug is already generic.

Far from ideal? It is far from close to the next-best thing, by a factor of 2.

Phase out fee for service, go to a capitation system.

from the trenches--stay far away from er's in nyc, at least now, with belleview and nyu med ctr closed.
I spent 20hrs last weekend at weill cornell, and it was like hospitals i hear of in the developing world. incredible--patients lined up gurney-to-gurney in halls and lobby, some seriously ill, no pillows blankets, people yelling heeelp and not getting attention--and we were moving relatively quickly, having been moved past trisge after a doctor friend called in on our behalf--many clearly indigent patients with no primary care who had let an ailment turn into something serious--when finally discharged, we noticed people who we had sat with still waiting at the very beginnming of triage, 20 hrs later, still potentially 20 hrs from discharge

and my doctor who called to get us prioritized says that, at this point, no matter how special or important or wealthy a patient is, they will face this kind of difficulty in ER's in ny

also, has anyone noticed that one can't post on price-chopper and successful lowball threads?--i have tried a few times and cant get anything to print

AR - I would love to continue discussion offline sometime, but I am not going to get into pharmaceutical industry online. As I have noted in the past, I generally love reading your perspective because I find you to be thoughtful and highly intelligent, but this forum is not right place for me to discuss further for a host of reasons.

Yikes - Yes, we all agree that ER situation is untenable.

>Limited? Scurvy is ok but not starvation? Sixth grade and you're out? Or tenth but you can read at a sixth grade level?

Limited as in you get education to 12th grade, then if you want more you pay for it or take our a loan that you will pay back. And if you borrow you be qualified in the first place and you learn something tangible that increases your earnings or value to society more than the cost of your degree. No anthropology educations paid for by the state.
Limited as in no starvation, no scurvy, but no cigarettes, caviar or booze.
Limited as in 12 months for your cataracts unless you cover the cost . Limited as in no unlimited dialysis if you made yourself obese.

my novice, fair enough. But I just want to throw this out there as food for thought, not specifically directed at anyone. Human Genome Project.

There goes the enology program at UC Davis.

"Medicare Spending Isn’t Out of Control"

A very detailed look at how Medicare spending has for 40 years and is projected to grow more slowly than private insurance plans (per person) DESPITE the fact that those 65 and older keep living longer.

http://economix.blogs.nytimes.com/2012/12/21/medicare-spending-isnt-out-of-control/?hp

Thought Jason was leaving us.

Jason, why are you letting facts get in the way of this discussion?

Why let the topic being discussed get in the way of non-sequitur?

AR - that was funny.

The facts in this article are pertinent to the discussion that was actually taking place:
http://well.blogs.nytimes.com/2012/12/20/where-have-all-the-primary-care-doctors-gone/

Long time passing.

Those are not "fact," novice - that is an opinion piece.

And, of course:

"Much of the problem lies in what general practitioners have to look forward to. General practitioners work as many hours as, or more, than their subspecialty colleagues. Yet they have among the lowest reimbursement rates. They also shoulder disproportionate responsibility for the bureaucratic aspects of patient care, spending more time and money obtaining treatment authorization from insurance companies...."

Once again, the fault of everybody but the poor, underpaid doctors who actually make twice as much as doctors anywhere else in the world do.

I'd like to see an empirical study about that, one not sponsored by an interested party. So far I haven't seen one.

Steve - click on the links in the article to see the underlying studies regarding the shortfalls. Those are the facts I am talking about. These shortfalls are occurring under the current system, and I believe such shortfalls would be even worse under the system you describe.

I will repeat for the third (?) time now that I do not dispute that your system "might" result in improved mortality rates at a lower cost to society as a whole (though I do not think it would - again, I subscribe to the theory that there are more factors at play in our diverse society and no study can answer the causation verse correlation here, as you have conceded). However, that is not the goal for everyone.

I understand that the goal for you is simply increased mortality rates at a lower cost. Re Jason, I am not sure what his goal is as he appears to pop in and out of all political conversations on this board with random statements and links that have nothing to do with what the posters in the conversation are actually discussing. If Jason took the time to read comments, he would see that the article he cited is entirely consistent with my position - a "medicare for all" system would likely result in higher taxes for everyone, as well as higher healthcare costs for those who use out-of-system providers. I would be okay with that and actually wonder if that might be the best approach.

I can't wait to see what, if anything, you post next. I taught a class once, and the students I found most entertaining were the ones who could not answer the questions I asked on the test, so they would write something that demonstrated some knowledge in the general subject matter.

Novice don't you understand? Steve is always right! Lol
He is delusional. Stop wasting your time.

Hi Brooks2 - I actually like Steve's posts because they frequently contain information that is of general interest to me, even if they are not always entirely responsive to what previous poster was saying. Regarding the back and forth between you and Steve, I wish I had a clue as what you guys were talking about. I never completely tuned into that one, but find myself entertained nonetheless. I like how you guys go back and forth without ever crossing any lines with personal insults in the exchanges I have read (but I have to confess, I have not read them all).

He knows enough about MBS to make him dangerous. Sounds the same on the health care issue. Your statement about teaching kids is right on, what he does not understand, he will fiegn then try to demonstrate some knowledge of the topic. Again enough to be dangerous

Novice, "career plan" surveys by the AMA are not empirical studies; what I said I would like to see is an empirical study by a group without an interest explaining exactly what the factors are that are driving physicians to behave as they do, preferably comparing the US physician market with others around the world. I have not seen that, the AMA study is not that, and one doctor's opinion as to what is driving it is not really convincing.

Brooksie, your knowledge of MBS's is provably nonexistent, so you should really shy away from criticisms of others. The fact that you would claim that bonds with negative convexity do not behave in the opposite way as bonds with positive convexity calls into question whether you even know that negative is the opposite of positive. Heaven help your kids if you have to insert batteries into their toys this holiday season.

That said, I don't comment a lot but I do comment on things I know about. I backed up everything I said with empirical studies. What I said is not an "opinion" - about health insurance or MBS's. It is an objective fact that negatively convex bonds behave in the opposite way as positively convex bonds. that is not "dangerous" - it is an empirical fact.

Merry Christmas.

Okay, now you are just being silly. Who other than physicians can explain the behavior of physicians? And I think we also have a disagreement as to what constitutes an empirical study because the various studies linked in that article constitute empirical studies in my world, which I believe is the one in which statisticians and economists live, but who am I to say? I am just a random voice on the internet. Happy Holidays and thank you for engaging in the discussion.

.Noviceounce you're just being silly. You honestly think that any self-interested group member has or will explain without bias their own or their group's behavior? Really? And I'm talking generally.I'm sure there are some.

iPad sucks

NYCNovice:

Why don't you just post an e-mail address, with your real name, so that you can "continue discussion offline sometime" for more "thoughtful and highly intelligent perspective..."?

HO, HO, HO!: You silly,real attorney!

AR - check out the studies in the article I linked and we can discuss further offline.
Truth - I have previously publicized my e-mail address for anyone who wants to discuss anything offline: foolish_renter@hotmail.com (it may be foolishrenter@hotmail.com - can't remember and not anywhere near my desk). AR seems to have moved past whatever is going on between you two in SE forums - can't you please do same for your SE community?  

Steve- heaven help you for being so obtuse. You behave exactly the way novice presented in her analogy about kids not knowing the answer then presenting some sort of knowledge on the subject matter. This is exactly what you do. Although I don't feel the need like you to blast my creditials all over the web(and I highly doubt the veracity of yours), I am positive I have more experience on the subject matter than you. You admitted you did not understand why a bank would buy MBS( I don't have time to search for your quote) then you said as though you came to some sort of revelation, oh! Banks buy MBS to hedge duration.., ? If you actually understood what duration was you would not say this. Additionally, you would not hedge duration with MBS. It is absurd to say that you would hedge duration with a negatively convex instrument. Bottom line. Yes it may make sense to a neophyte like you that since positive and negative are opposites that this makes sense. If you had any background in finance of portfolio management you might understand. Since you don't I would stick to making coffee for the lawyers you work for and just translate the topics for them because you don't seem to understand much. Before you know it I am sure you will be blasting out how you have some sort of engineering or mathmatics credentials too. Steve you are a joke. I truely do laugh at people like you.

"I am positive...."

Brooksie, Brooksie, Brooksie, since you don't know the difference between positive and negative convexity (or that banks don't keep most of their originated mortgages on their books, or that what you were looking at were not "closing prices," etc., etc.), that statement means little.

"You admitted you did not understand why a bank would buy MBS( I don't have time to search for your quote)...."

You can't find it because it doesn't exist.

"you would not hedge duration with MBS. It is absurd to say that you would hedge duration with a negatively convex instrument. Bottom line."

Bottom line, case closed, HAHAHAHAHAHAHAHAHA! I posted dozens of links where it says precisely that MBS's are used to control duration list, and your answer is "Bottom line."

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA! What a maroon.

So let me repeat: "Traded mortgage-backed securities, euro-dollar futures contracts, treasury futures contracts and options on mortgage-backed securities to hedge interest rate volatility for banks%u2019 mortgage pipelines."

http://www.linkedin.com/in/kmapel

"Delivered product to investor on a Mandatory and AOT basis utilizing Mortgage Backed Securities to hedge the interest rate risk."

http://www.linkedin.com/pub/kevin-keadle/6/2a6/296

Just make sure you don't put the positive pole of your battery in the negative slot this Xmas, eh, Brooksie.

Novice, "Who other than physicians can explain the behavior of physicians?"

A survey does not analyze the reasons why physicians are making those decisions.

"And I think we also have a disagreement as to what constitutes an empirical study because the various studies linked in that article constitute empirical studies in my world...."

Then your world is wrong.

Sigh. Let's change the subject - how do you feel about coops? :-)

NYCNovice: Your real name is foolish_renter?

Nothing is going on between us in SE forums.

I'm not running for Miss Popularity in the SE community.
Can't you please do the same for your SE community?

P.S.: jason was spotted in Nob Hill wearing a "I'm still ignoring NYCNovice" tee-shirt.

Bill Clinton was spotted trying to stuff himself down Ron Burkle's chimney last night.
Can't Bill do the same for Hillary?
She's been too tired, dehydrated, and suffering from a concussion that she "just can't" testify before the congressional panels looking into the terrorist attack in Benghazi.

You know, the one that murdered Ambassador Chris Stevens and three other Americans?
The attack that the Obama administration blamed on a YouTube video?

You're just too silly!

stevejhx
about 3 months ago
Posts: 12312
Member since: Feb 2008
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I have seen no evidence that banks are buying Agency MBS's, because they have no incentive to. Moreover, the logic makes ZERO sense (as usual): Agency MBS's have as underlying assets agency-qualified (guaranteeable) mortgages. Therefore, it is impossible for them to buy agency MBS's because there are not enough qualified buyers, because agency MBS's are comprised of qualified buyers.

Found your quote Steve...,. Lets see you BS your way out of this one...

Better NY poser

Oh the links you post are taken out if context. If you understood what you were talking about maybe you would realize this.

Fool

"Price controls coming for health care" sure, also rationing, there's no way to pay for Medicare / Medicaid escalating costs otherwise.

Brooks2:
stevie seems to have moved past whatever is going on between you two in SE forums - can't you please do same for your SE community?

Or, maybe stevie is just taking a Christmas Day break.

Brooks may have dug up some proof in his Christmas pudding.
I say: Keep the debate going.

Maybe Miss Goody Two Shoes will come back to give you a lecture.

jason10006
4 days ago
Posts: 4530
Member since: Jan 2009
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"Medicare Spending Isn’t Out of Control"

A very detailed look at how Medicare spending has for 40 years and is projected to grow more slowly than private insurance plans (per person) DESPITE the fact that those 65 and older keep living longer.

http://economix.blogs.nytimes.com/2012/12/21/medicare-spending-isnt-out-of-control/?hp

Who is Miss Goody Two Shoes?

Looks like Jason the Retard has become Stuttering Jason the Retard.

jason10006
about 8 hours ago
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jason10006
4 days ago
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"Oh the links you post are taken out if context. If you understood what you were talking about maybe you would realize this."

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA!

Hundreds of links, every single one of them "out of context."

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA!

What a maroon.

And the link that you re-posted (out of context - HAHAHAHAHAHAHAHAHA!) is correct, and I posted links to Federal Reserve data to prove it.

Post the whole thing, maroon. That clearly shows that banks did NOT materially increase their holdings of MBS's.

I didn't say - as you claimed - that I didn't know why banks would buy MBS's. I said that there was no evidence that they were materially increasing their holdings of MBS's.

And there's not.

So, Maroon, now that you've claimed that my hundreds of links are all taken out of context, why don't you post JUST ONE?

PS: Did you get the negative and positive poles on your batteries right yesterday?

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA!

What a maroon!

Give us your exp

oops! "Give us your explanations...."

MAROON.

A huge amount of our health care dollars are spent during our final months of life. I am not talking euthenasia; but until we as a society come up with ways to allow people to die costs will never be contained.

And btw; like military spending, if and when health care spending is controlled some we will have millions of people added to the unemployment rolls. These are two major employers and I don't see alternatives for those who will lose their jobs

It's more than that - my brother-in-law the surgeon said it yesterday: his salary is just a small part of what he earns; if he doesn't operate on people, he doesn't make money.

So guess what he does?

It's not a study, but it's interesting nonetheless:

http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?partner=rssnyt&emc=rss

Silk thread or staples?

Oh - and my brother-in-law rails on and on and on about Obamacare, but he LOVES his state-owned and -subsidized Nassau County golf courses. Welfare for the rich is fine by him.

Unless he is a concierge dr, a growing class, he is also quite happy with his medicare patients, esp those with supp insurance.

Yikes - can you explain to steve what a concierge doctor is and that this group is in fact growing?

Brooks2 - I think steve's professed degrees are real; if one were inclined to fabricate credentials, I can't imagine his professed degrees are the ones one would choose.

> A huge amount of our health care dollars are spent during our final months of life. I am not talking euthenasia; but until we as a society come up with ways to allow people to die costs will never be contained.

it's not only about increasing costs as boomers retire, but mostly about who pays that cost increase. as that increase is not being able to be paid by wage taxes, more and more wealth taxes (coming mostly from the wealthy elderly) will have to foot the bill for that.

imho it'll be interesting to observe how the AARP discourse about costs shifts as aging costs stop being entirely funded from wage-earners (young transferring wealth to older) towards a combination that includes asset owners (older rich transferring to older poor).

Clark: There's no problem. I was just hoping you could give me some insight into the evolution of the market economy in the southern colonies. My contention is that prior to the Revolutionary War the economic modalities, especially of the southern colonies could most aptly be characterized as agrarian pre-capitalist and...

Will: [interrupting] Of course that's your contention. You're a first year grad student. You just got finished some Marxian historian, Pete Garrison prob’ly, you’re gonna be convinced of that until next month when you get to James Lemon, then you’re gonna be talkin’ about how the economies of Virginia and Pennsylvania were entrepreneurial and capitalist way back in 1740. That's gonna last until next year, you’re gonna be in here regurgitating Gordon Wood, talkin’ about you know, the Pre-revolutionary utopia and the capital-forming effects of military mobilization.

Clark: [taken aback] Well, as a matter of fact, I won't, because Wood drastically underestimates the impact of--

Will: ..."Wood drastically underestimates the impact of social distinctions predicated upon wealth, especially inherited wealth..." You got that from Vickers. "Work in Essex County," Page 98, right? Yeah I read that too. Were you gonna plagiarize the whole thing for us- you have any thoughts of- of your own on this matter? Or do- is that your thing, you come into a bar, you read some obscure passage and then you pretend- you pawn it off as your own- your own idea just to impress some girls? Embarrass my friend?
[Clark is stunned]

It's more than that - my brother-in-law the surgeon said it yesterday: his salary is just a small part of what he earns; if he doesn't operate on people, he doesn't make money.

So guess what he does?

It's not a study, but it's interesting nonetheless:

http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?partner=rssnyt&emc=rss

Silk thread or staples?

Oh - and my brother-in-law rails on and on and on about Obamacare, but he LOVES his state-owned and -subsidized Nassau County golf courses. Welfare for the rich is fine by him.

Your brother-in-law is an unethical a-hole. No better than lawyers who bill for hours they don't work or the Wall Street guys who sold stocks to their clients that internally they referred to as "sh*t." There isn't a profession or business that doesn't have opportunity to rip people off - ethical people don't take that opportunity

Why would I fake a degree from Columbia university?

Steve has long said he has a degree from Columbia, as well as George Washington.

Yes, I believe Steve has an undergrad degree in econ from GW from either the late 70's or early 80's;
I believe Steve has some sort of certificate in finance from NYU;
I believe Steve has a masters in Latin American culture or studies from Columbia.
From where I sit, none of those are authoritative on any of the subjects Steve has put them out there for, which is why I feel he would not fabricate them. Steve is in litigation support, so I am sure he is familiar with the credentials of those attorneys choose as experts, and I seriously doubt Steve would offer himself up as an expert to testify in any of the ongoing litigation regarding mortgage backed securities, and he certainly would not offer himself up as an expert to testify in healthcare economics. Were he to offer up said credentials, he would be summarily dismissed. That is why I can't figure out why he mentioned his degrees at all. I am not taking anything away from Steve's education; my point is that it does even get him in the running to be an expert.

bob420- Amen.

I don't see what not being a lawyer has to do with not offering up my services as a lawyer, though I do see what credentials lawyers have who are "chosen as experts," and I also know that despite those credentials, half of them lose.

Let me guess: In your lit support role, you frequently think to yourself how you could do the job better than the lawyers you are supporting. We all know and enjoy the type.

I've never had that thought, but thank you for sharing your Psychic Skills, limited though they are.

Clearly not a psychic; just trying to figure out your point re credentials, lawyers' or others'. If you don't think they matter, why introduce them into the debate? If they do matter, then introduce credentials that carry authority.

PS - experience in whatever is being discussed carries greatest authority for me personally, but I am only one member of the audience. Maybe your academic resume, such as it is, carries weight for others.

Your psychic powers are indeed poor, though if one is discussing bonds - which is what MBS's are - and one has taken 9 or so courses studying bonds, and has a recognized certification in bonds equivalent to all the undergraduate coursework for a degree in finance and then some, and one knows how to price bonds and has done the calculations himself, one may state this, especially when engaging with a buffoon who does not know that the prices he was looking at on the Wall Street Journal were not "closing prices" for MBS's, but rather benchmark returns calculated based on assumptions of prepayments, among other things, such as the fact that bonds with negative and positive convexity behave oppositely when faced with changes in market interest rates.

Then, if one is discussing the economics of healthcare, having a degree in economics is certainly a relevant point, especially when engaging with a) said buffoon; and b) an alleged physician who would know a lot about medicine but maybe not so much about the economics behind the market for healthcare, which is an entirely different subject.

And what you claim are "my opinions" are nothing of the sort; all I did was quote from studies performed by people with greater expertise in their respective fields than I have. I am extremely well qualified in my own field - one of the best - but not in all fields, or even in most fields. However, I'm smart enough to read and understand what I'm reading.

That cannot be said for people who believe that negatively and positively convex bonds behave in the same way, or people who make vast claims about the quality of healthcare in the United States that are completely devoid of any fact-based study that I have seen. In fact, every study that I have seen has shown that the US ranks among the lowest in mortality, morbidity, quality, and access to healthcare among all countries in the world, and we spend twice as much as a percentage of GDP as the next most expensive system to reach that dismal position.

No one has yet posted any study based on real facts - not opinions or guesses or surveys - that would disprove that, any more than they have shown that positively convex bonds behave in the same way as negatively convex bonds.

And the reason why no one has posted any study such as those is because they do not exist.

You are free to maintain whatever "opinion" you like about either subject, but such a belief amounts to fantasy.

Steve - get a grip. Where did I ever talk about any opinion you hold? All I have said is that your goals are different than mine and that I do not draw same definitive conclusions that you do from data presently available in healthcare. Maybe your last post was directed at someone else?

"Get a grip"? You mean after "If they do matter, then introduce credentials that carry authority," so I answer it, and that requires a "grip"?

This time it's your memory, not your Psychic Powers.

"All I have said is that your goals are different than mine"

I haven't stated my goals.

"I do not draw same definitive conclusions that you do from data presently available in healthcare"

Let me repeat: they are not MY conclusions; they are the conclusions of dozens of studies based on real, hard data. If you could show some real, hard data to support your "conclusions" I might be impressed.

Thus far, though, you've quoted a career goal survey, which is decidedly unimpressive.

Oh my. Backing away slowly . . .. As I stated previously, you make an excellent case for your position, and I respect it. I understood your goal to be better mortality rates at a lower cost. I apologize if I misunderstood and have repeatedly stated that my own reading comprehension skills are not perfect.

My goal is not "better mortality rates at a lower cost," nor has it ever been. Mortality rates are an indicator of healthcare quality; not the only one, but a primary one. Others are morbidity rates (a bit more difficult to determine), quality of care (ditto), and access to care (easier to determine). But logically, mortality rates are affected by morbidity rates, quality of care, and access to care, so they must be considered a primary factor when evaluating the overall effectiveness of a healthcare system. Mortality rates do not affect morbidity rates, etc., etc., because mortality is pretty final, IMHO.

The goal - not mine, but the country's - should be a healthcare system that achieves mortality and morbidity rates in line with other OECD countries, at a similar cost (adjusted for differences in populations, etc.). Such a goal would be achieved by providing better quality care to more people, at a lower cost.

There is not a single study I am aware of that rates our healthcare system highly - not statistically (mortality / morbidity / access) or in terms of quality. The facts are that we are ranked #38 worldwide for mortality and morbidity, and it cost us twice as much as the next contender to get a much worse result.

So something must give - our system must be redesigned. Or as my brother-in-law the surgeon also said at Christmas, "Nobody used to, but now everybody gets an MRI."

Sure - you get reimbursed every time you do one, needed or not. And apparently most of them aren't needed, because if they were it would show up somewhere in the statistics.

Surgeon's make more money if they operate; Radiologists do not order their own MRI's.That expense (huge on a societal basis) are defensive and protection against malpractice

No those expenses are not "defensive and protection against malpractice." Sorry - sometimes MRI's are needed; most times a simple X-ray will do. Hospitals order MRI's because they buy the machines and need to cover the costs.

We're all paying for it.

Only a physician can order an MRI. Yes; many times a regular X-Ray will do. BUT the people who actually order it do not share in the profit

Actually, many MRI facilities are owned and operated by physicians, and they DEFINITELY profit from ordering MRI's. It's one of the dirty little (not so) secrets of the medical profession.

I personally think we benefit from MRIs and the improved diagnosis available. No longer do surgeons have to cut to see what's inside.

Yes, physicians get paid for every procedure they do. That's why they do them.

For MRI's:

http://www.icadmed.com/support/reimbursement/documents/ReimbursementGuideRev_D_withcover_FINAL2_7_11.pdf

And here's what happens:

http://www.kevinmd.com/blog/2010/01/doctors-united-states-order-ct-scans-mri-tests.html

The US has twice as many CT scans and MRI's as the OECD average, yet our outcomes are the worst among the OECD, and below Guatemala's.

http://www.nytimes.com/2004/03/13/business/an-mri-machine-for-every-doctor-someone-has-to-pay.html?pagewanted=all&src=pm

Once the MRI is performed, the doctor gets paid for interpreting it. The hospitals that doctors are affiliated with are also very appreciative of the business (wink wink).

It's not the only thing that's wrong with our system, but all of it is caused by fee-for-service.

Unless you're one of the one who believes that it's everybody's fault but the doctors'.

Actually you guys are all partially right and wrong about MRIs. First of all, I am a radiologist and own and operate MRIs so my statements will definitely be biased about this. But the basic rule works like this, you cannot be a referring physician and order MRIs at your own facility and receive the revenue from the MRI in most states. NY state is an exception. Approximately a dozen states have this exception (and the tide is shifting towards shutting this practice down). The studies have shown that orthopedic surgeons and neurologists that own their own MRI machines refer their patients for significantly more exams than those that refer to an outside facility (such as mine) where they receive nothing in return (except, hopefully, good service).

These rules were created to make it easy for a doctor to put an xray machine in their office. I believe that is a reasonable convenience and at minimal cost to the patient/insurance company and don't actually have an issue with xray machines in referring doctors' offices (even though this still ultimately cuts into my revenue). I am not a big fan of having MRIs in their offices, though, especially due to the over ordering of unnecessary studies. What is even more frustrating is that the private insurance payers make it VERY easy for a referring doctor to do this (by easy I mean they will accept most of these referring doctors as in-network with minimal fuss). On the other hand, most radiologists in the city have a very difficult time getting on the same insurance panel in-network (even though we ultimately save them money as we cannot order any tests). In fact, even if someone pays cash, we don't order the test as it is a conflict of interest. Radiologists have spent a significant amount of money to try to stop this practice, but ultimately we are a small speciality with a very weak lobby (compared to the surgeons), and progress has not been as quick as it should be (in my opinion).

Also, hospitals do not "order" MRIs. Doctors do. For an outpatient, the hospital receives payment for the MRI of between $1000-$2000 for the study (as opposed to the outpatient practice setting where payment is approximately $300-350). In reality, there is VERY little push from hospital administration to push for MRIs as the monthly revenue for MRI is less than a 4hr day for the OR (even that's a stretch).

Also, the vast majority of MRIs and CTs in a hospital are for ER or inpatients (depending on the hospital, this is about 50-95% of the population, although it may be different in the midwest or south). For inpatients and ER patients, the hospital only gets paid a flat fee based upon the initial ER diagnosis code. They do not get paid extra for each MRI. In fact, every time they do an MRI it increases their costs and they get no revenue from it. Actually, there is pressure from "above" to NOT perform complex imaging studies (CT/MRI) for the inpatients or ER patients. It is not overtly aggressive (meaning I have never heard of anyone being fired or taking a pay cut) but it is very clear to the ER and inpatient doctors that ordering MRI or CT tests is a drain on the system and should be avoided unless absolutely necessary. Those who over order are definitely spoken to privately and warned to "get in line" with the program. Of course, if a patient has a complex problem that requires a longer stay, the diagnosis code can be modified and the hospital may receive additional payment, but again, it is for the diagnostic code, not for additional studies. They are capitated. Of course the fees that they receive are quite substantial for this capitation.

When I was in training, it was very fashionable for the radiology residents to ridicule the ER docs for over ordering tests that ended up being negative. I have had several experiences myself where I as laughing at the ER doctor's diagnosis and ultimately when the patient was scanned, they had a life-threatening emergency (pulmonary embolisms, DVTs, aortic dissections, intracranial hemorrhage). The patients I saw prior to the scan had symptoms, but they were very "weak" and I would have never guessed that their studies were positive. Needless to say, this both humbled and scared me, and now I don't make it a point to make any determination until I see the images.

There is a limit to this, and, ultimately we cannot afford to scan people constantly. Ideally we would have a more accurate way to pre-diagnose people but when you read the literature about various conditions, it is somewhat disheartening as we have not made much progress in this category. Without a doubt, there is a high fear of missing a diagnosis and malpractice and a large proportion of studies are done to "cover your ass". I know there is a suspicion that doctors are constantly ordering tests for their own benefit but as discussed this is a VERY small amount of physicians and only in certain states. Even in NY state, of the 300+ doctors I know personally, I only know of 2 that own their own CT or MRI machines. For the vast majority of doctors, it is more time efficient to not order anything because it takes time to follow-up and get approved. Mostly, they order when the literature supports it, but the literature is not very specific for most conditions.

There is some truth to that. There is some truth to this, as well:

http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html?pagewanted=all&_r=0

and this:

http://usatoday30.usatoday.com/yourlife/health/healthcare/hospitals/2010-10-09-er-scans_N.htm

It's part of the problem.

btw after saying all of that, i will say that the only way to get costs down is to work on end-of-life care first. that is the vast majority of the cost. ~70% of care is spent on the last month. also no amount of capitation will affect this because the hospital will undoubtedly use this as part of their calculation and negotiation process for the capitation cost. I do not believe CMS will fight them on this either as it is too hot of a political topic and unless it is paid for, the hospitals will go under anyways and they don't have a legal choice to opt out of this "care".

only the legal system can impact this change. in many states, ur advance directive is not a true directive but just a "hint" of what you want done with your health. it cannot be legally followed if the patient's family disagrees with it. the republicans love to call these "death panels" to scare people but it is one of the most important things that needs to be fixed. each end-of-life ICU patient can cost about $1 million per month. I have seen patients there for several months in their 80s and 90s. if we fixed this problem, we could cut about half of the overall medical costs and then our overall costs would be inline with the vast majority of western countries.

I fully agree with end of life care, but it does not account to anywhere near "70% of care."

According to the NIH, it is 10-12% of all healthcare spending:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282187/

But even that can be reduced, if you can get through the "Death Panel" nonsense.

And one more fallacy exposed.

Also, it is decidedly NOT TRUE that physicians are prohibited from self-referring to MRI's that they own:

"Since the early ’90s, doctors have generally been barred by federal law from referring patients for certain services —including imaging and lab tests — to entities in which they have a financial interest. But that law exempts doctors who provide such services in their offices. Lawmakers figured it would be more convenient for patients if the doctors could get an in-house X-ray to make a diagnosis.

"Over the past several years, cardiologists, orthopedic surgeons, urologists and other specialists have used the exception to buy increasingly high-tech and expensive imaging equipment for their offices.

"Some doctors have leased time on machines at existing imaging centers, arguing that the centers were part of their office practices and thus exempt from the self-referral law, according to the Medicare Payment Advisory Commission, which advises Congress on Medicare issues. This trend has infuriated radiologists, who are expert at reading images and find themselves competing with other specialists who are opting to move or keep their tests in-house."

http://www.kaiserhealthnews.org/stories/2010/august/23/physician-self-referral-health-law.aspx

You really need to get your facts straight, 1234, before posting this crap.

stevejhx

u realize any doctor can buy a machine and put the machine in their office and charge patients cash, right? i am not denying that. the insurance panels which allow you to become in-network vary by state (actually by city and zip code). it is the insurance panels which will not allow it (almost all states) and the vast majority of doctors cannot survive on cash payments. united oxford will not pay an orthopod for mris performed in their office in most states, they will simply reject the application.

of course, what would i know? this is all i do day and night... as a language translator i'm sure u have dealt with this regularly. the articles u post are as in-depth as the articles barron's posts on stocks. why don't u forward them to the guys at 85 broad, so u can teach them a thing or 2 about finance as well...

every single poster on this forum has called you out for what u are. a know-it-all who knows nothing. u r what is wrong with this country. if people actually educated themselves before speaking and "knowing" we would probably not be struggling the way that we are. what is shocking is that u r not a 20yr old know-it-all but an adult (i'm guessing in ur 50s or 60s). read books and stop copying and pasting the first link that google sends u to. depth of knowledge is more than "googling" otherwise people would simply use google translate instead of wasting their time with an arrogant asshole. half of the crap u post is so broad and generic it is useless.

it is VERY clear what all your posts are about. they are about ur lack of self-esteem. perhaps if u were not a D student, you too could have earned your way to a respectful living instead of telling others how to run their businesses. i would love to meet the "surgeon uncle" of yours just for a few laughs. also i suggest u cut back on the donuts.

Really, 1234, resorting to ad hominem attacks on me and my alleged "low self-esteem" just because I called out your plainly false claims based on information from the National Institutes of Health and Kaiser Permanente is truly unbecoming.

So first we go with it's the "states," now we go with "insurance panels," and I'm sure you are intimately familiar with every "insurance panel" in the country. Note, however, that I did not say ONE WORD about what insurance companies would allow - I don't have their contracts so I can't tell you, though it would seem highly unlikely that doctors would be buying these machines in such vast numbers - and doing so many MRI's and CT scans compared to our OECD cohorts - if they weren't making money off of them. Moreover, as you know, many insurance companies follow Medicare's reimbursement rules, and it is plainly allowed under Medicare (and Medicaid).

What it seems to me that you don't like is when people call you out for BS.

And my brother-in-law is a surgeon, not my uncle.

ps I never mentioned cash, either. That was novice.

>every single poster on this forum has called you out for what u are. a know-it-all who knows nothing. u r what is wrong with this country. if people actually educated themselves before speaking and "knowing" we would probably not be struggling the way that we are. what is shocking is that u r not a 20yr old know-it-all but an adult (i'm guessing in ur 50s or 60s). read books and stop copying and pasting the first link that google sends u to. depth of knowledge is more than "googling" otherwise people would simply use google translate instead of wasting their time with an arrogant asshole. half of the crap u post is so broad and generic it is useless.

>it is VERY clear what all your posts are about. they are about ur lack of self-esteem. perhaps if u were not a D student, you too could have earned your way to a respectful living instead of telling others how to run their businesses. i would love to meet the "surgeon uncle" of yours just for a few laughs. also i suggest u cut back on the donuts.

Someone is about to call someone else a "gay translating accountant."

Oh, if you want to see what in-office tests Oxford will pay doctors for, you can find them here:

https://www.oxhp.com/secure/policy/oxfords_in_office_laboratory_testing_and_procedures_list.pdf

And regarding exactly what orthopedic specialists do with their MRI's, some information is here:

http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/%7B8F1B817D-741F-4914-9C7F-5FC7FEEBE8DA%7D/Physician-owned-ancillary-care-facilities-can-provide-financialboost

“The ancillary revenue streams can add a significant amount to your overall income,” Burkhart said. “However, we don’t market our services to other doctors.”

Explains your Stark laws in pretty much detail, too - toothless, I should say.

It's ALL ABOUT THE MONEY, so best just to admit it.

feint, bs reference post, feint, bs reference post. all in your quest to cling to your dogma. hilarious that you continue to call bs on the folks who work in the field everyday and beyond that have obvious factual insights and thoughts and suggestions on how things can be made better.

feint, bs reference post. nothing to see here, move on folks cause stevie is on his ever-shrinking soapbox.

charlotte the "new" center of banking, short the market at 9k, continued to short the market but radio silence after another 16% run-up this year. now he is lecturing us on healthcare and negatative convexity, just freeking hilarious. oh, lest us not forget the brilliant re purchase of property on a sandbar pre-Sandy. you deserve all that after your continuous feint, bs post routine. its old.

apparently steve doesn't live up to rangerfan's high standards.

happy new yrae hb

Thankfully, when Jason the Retard is on vacation, Rangerfan is here to entertain us.

For Stevejhx: http://mobile.businessweek.com/articles/2012-11-29/is-concierge-medicine-the-future-of-health-care

P.S. - My point in posting the above is that there is in fact a trend that Steve has professed no knowledge of of physicians opting out of insurance networks entirely, and I reiterate my point about his lack of credentials in this area that he is professing expertise in. I am certainly not an expert in this area and would not even put myself in the well informed category, but reading the back and forth, I remain inclined to give the greatest weight to nyc1234 point of view. This is obviously an incredibly complex subject that I cannot imagine anyone can fully grasp unless they are fully immersed in it. Despite the fact that Steve has professed to have no time to read outside of his work, and despite the fact that this subject matter is not part of Steve's work, I do not doubt that Steve has read quite a bit about the subject and I find his perspective interesting and informative, even though I would not vote for the approach he is advocating.

They didn't "opt out of insurance"; they set up their own insurance system by charging a flat fee per month, they gist of which is, “I want to be one of the 1 percent,” says Umbehr, who likes to talk business as much as he does medicine; Ayn Rand’s Atlas Shrugged inspired the name of his two-year-old practice. “But the problem with the 1 percent is there’s only 1 percent of them. If you want to build a business model that’s really far-reaching and world-changing, then it’s got to fit everybody.”

You can give all the weight you want to 1234 or anybody else - doesn't bother me. If you think that a person who claims that "70%" of Medicare is spent on end-of-life care when the National Institutes of Health states that the figure is about 15%, feel free.

None of what I said is "my" opinion - I only quoted what every study ever performed said, and I provided the links for it to read yourself. If you don't believe the WHO, CBO, NIH, Kaiser Permanente, etc., or even the article written by doctors about how they can up their income by performing (apparently unnecessary) MRI's, then so be it. The world is full of people who believe only what they want to believe, in the face of all evidence. Just add yourself to the list.

What type of regulation, if any, would you impose on concierge medecine? As long as you let these folks practice medecine on their own terms, I am less inclined to worry about whatever else you want. If you read entire article, you will see at the end the spectre of regulation coming in to hinder physicians who make this choice. I believe that if we take this option away, we will lose some existing physicians, and we will see even fewer of the best and brightest choosing medecine. The article was also interesting to the extent it distinguishes between various practice areas for physicians - what is tenable business model for one group might not be so for another. Makes me wonder whether obamacare has winne ars and losers between physician groups, which is why I am drawn to nyc1234 points re private hospitals benefitting at the expense of more efficient independent practices in certain areas. Only time will tell whether we as a society are better off down the road. In the interim, I cannot help but feel for the physicians who entered the profession under one set of rules and are now having the rules changed on them.

The concierge system is facing some serious insurance fighting-back. Many health plans now only cover a hospitaization/surgery if your doctor is in network. The deductibles for PPO's are skyrocketin. Many people are willing to pay a few grand to see a concierge doc - many fewer will put up 50K for a surgical procedure.

The old major medical insurances paid well enough out of network for things to work. That is no longer the case

I think that if a doctor's goal is to be in the "1%" then he chose the wrong profession.

>I think that if a doctor's goal is to be in the "1%" then he chose the wrong profession.

Personally, I hate when I see a child of a doctor in a field such as finance. They want money and have been turned off by the difficulty of medicine having seen it up close through their parent - be that the required training, the economic aspects, or the bureaucracy. This will happen more if we create a system that treats doctors as commodities or government pawns.

hb, wtf was that you just wrote? is it even english?