Price controls coming for health care

liar.

liar.

keep going.

still a liar.

Let's say I am a
"liar.

liar.

keep going.

still a liar."
You still haven't managed an ounce of defense for aboutready's money-pocketing situation. That says a lot.

liar.

I wonder how aboutready feels about this.
Lots of people don't like me, but no one - not even COlumbia COunty - has been able to defend her position on this situation where she is pocketing money that belongs either to the people of the State of New York, or to the poor and working class of NYC.

liar.

huntersburg:
The new programming starts in April. Enough time for the deal to be completed.
Their marketing slogan is:
"Inform, inspire and entertain!"

your very own groupie.

yuck.

>your very own groupie.

But still no justification for aboutready's actions against the poor or the taxpayer.

how many times have you said that you're 12 yrs old? is that true. or just another lie?

>how many times have you said that you're 12 yrs old? is that true. or just another lie?

New topic even without resolution of your point of view on the aboutready / lawsuit issue?

are you 12?

or was that just another lie?

>are you 12?
>or was that just another lie?

I'm not 12. I was merely reflecting the people - aboutready in the lead - who repeately accused me of being 12. I'm sorry you didn't understand what was relatively clear to just about everyone else here.
w67 accused me of living in a flooded east village studio. That also wasn't true.
But I've never taken proceeds of a lawsuit that should go to the poor or working class.

so...all the times that you said you were 12.

that was a lie?

I repeated others points of view that I was 12. Did they believe I was 12? You tell me.

Yet another cc post diverting attention from mistreating the taxpayer and the poor.

you said that you're a liar and a fraud. is that another lie?

Did you believe I was 12 and yet you continued to engage me?

how can anyone believe anything that you say?

are you not just the troll.

hfscomm1.

Columbiacounty, why do you have an interest in 12 year olds?

And why does aboutready take from the poor?

as the novice would say...i rest my case.

>as the novice would say...i rest my case.

Were you hoping for jurors who are 12?

huntersburg:
I'm discussing the Al Gore/ Al Jazeera situation with you and now c.c. wants your undivided attention.

By the time I get back from Australia in April, I will have earned 60-75k, since this past New Years week working in San Francisco, a few days here in Maui, all from working non-9-5 days.
I pay my taxes.

It's time for a nice swim.

Hope it's a good winter for you.

Wishing the streeteasy community well until then.

Yup, novice.

Yup.

Here's an interesting article with links to real studies:

http://www.nytimes.com/2013/01/09/business/health-care-and-pursuit-of-profit-make-a-poor-mix.html?ref=politics&_r=0

Steve - I think I need to clarify that I do not mean to imply that The Economist shares my POV; the editors have taken no position re values or future and there is much in their coverage of healthcare policy that can be used to support your POV. But actually the best article I found supporting your POV was this one from Atul Gawande: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
I really do see both sides of this debate.

I also need to correct statement re physician who ultimately diagnosed and treated my father-in-law where previous physicians had failed. I asked my mother-in-law for more detail and the issue was medicare reimbursement; physician had not opted out of medicare but medicare would not pay even though CMS agreed that treatment was "medically necessary" because treatment was not FDA-approved. Accordingly, payment had to be out of pocket, and the expense would have been prohibitive for most people. What happens to such patients in England? Genuinely curious.

Finally, what did Mayo Clinic ultimately decide re accepting Medicare patients? This is one of the "research further" questions on my long list on this topic, but as long as I've got an interested party on the line who might know the answer off the top of his head, thought I'd ask.

NYCNovice: the U.K. is not single-payer (unlike Canada). Physicians work part-time for NHS and some have substantial private practices. You just pay out of pocket, and may be reimbursed by private supplementary insurance (BUPA).

I think that the costs are lower in the U.K., even if you are pay 100% out of pocket. I have only one point of reference - a double hip replacement operation by top surgeon cost $40k USD. That doesn't seem bad to me, considering the 1-week long hospital stay, 12 hour surgery, etc.

nyc10023 - Interesting. So results for my father-in-law might well have been same in England. I am intrigued by British system, but I know U.S. would never require physicians to be part of a national system. Not my area, but even if legislature were to pass such a system, it feels unconstitutional. I also do worry about innovation, waiting times, and supply of physicians. See, e.g., http://www.economist.com/blogs/blighty/2012/11/health-reforms

A more recent article about current state of NHS: http://www.economist.com/news/britain/21569038-health-secretary-has-made-intriguing-start-tough-job-styling-himself-patients

nyc10023 - the UK spends less per person in USD$ terms and less a percentage of GDP on HC than does Canada, so yes, the overall system costs less. This INCLUDES private doctor services. Yet the outcomes - life expectancy, infant mortality, etc., are better on average than the US in both places, and are comparable to each other.

"treatment was not FDA-approved."

No insurance will pay for non-FDA approved treatments, private or otherwise.

Mayo Clinic accepts Medicare.

"but I know U.S. would never require physicians to be part of a national system."

Don't count on it.

NYCNovice: the British system isn't bad. They have less restrictions on foreign physicians practicing medicine compared to Canada, so presumably that increases supply and decreases cost. Quality of care depends on postcode (google postcode lottery healthcare) but that's the same as everywhere - rural areas are bad everywhere for access to health services.

One aspect of a somewhat-public healthcare system that we haven't talked about is its democratizing effect. Same goes for education. Or probably any large government-run service.

Even in the U.K, with its fee-for-service tier, the vast majority of English people, rich or poor (including the Royal Family - NHS treated Princess Louise as infant, Cameron's now-deceased eldest child was very ill) have experienced care in a public setting.

I think (not substantiated by any study that I can cite) that creates public support at all levels for a public health safety net that is not "last resort". Most major degree-granting institutions in Canada are public (all the top ones are). Ditto U.K., ditto Australia. In the U.S., one can be completely insulated, even if not very wealthy if you have good insurance from the world of the uninsured or badly insured. You can be completely insulated from state-funded education from K to grad school.

nyc10023 - Democratizing effect falls into the value judgment area. Down the road, Americans may vote in that direction, but I don't see it happening in my lifetime.

stevejhx - Same response re "don't count on it." Only time will tell.

I can't make any comments about Canada or Australia, but the US & UK education systems are vastly different and can't remotely be compared. What we here in the US call a "private university" essentially does not exist in the UK; there are but 2 universities whose tuition is not subsidized by the British government (University of Buckingham and The University of Law). Nonetheless, students still pay a hefty tuition.

I don't think that that structure has any bearing on what people feel about the NHS - though it has its critics, it is pretty much universally loved.

"but I know U.S. would never require physicians to be part of a national system."

Don't count on it.

^ This is Steve's dream.

---

Do you think there is no profit in capitation?

We spend the most per person in $ terms and as a percent of GDP - 50% more than the #2 country, Switzerland, which has a ONE HUNDRED PERCENT PRIVATE SYSTEM, and more than 2X the UK. And yet ANOTHER new report says: "...The title sort of says it all: "U.S. Health in International Perspective: Shorter Lives, Poorer Health."

The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although life expectancy and survival rates in the United States have improved dramatically over the past century, Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries.
The report compares the U.S. to 16 other rich countries, including Canada, the United Kingdom and Germany. To those who know, the results aren't surprising. But they are unsettling: Life expectancy is worse in the U.S. than in most of those nations; the infant mortality rate is the worst..."

http://www.huffingtonpost.com/jeffrey-young/american-health-worse-tha_b_2441236.html

Thanks for this fresh perspective Jason. I don't believe that link has been copied and pasted yet into this thread. Congrats for your quick "ctrl" skills. You were able to plagiarize this article in under 4 hrs, something even Steve can look up to.

life expectancy and survival rates have a correlation to healthcare but stevie would have you believe that its the centerpiece for our "failed" system. wrong. lifestyle, especially obesity rates probably skew these numbers to the detriment in the US. Rightly so, but nothing to do with the measurement of healthcare here. Stevie would like to commoditize healthcare becuase he is smarter than all the docs out there and they are nothing more than looking to bankrupt him and since he can self-diagnose anyway, they dont have any real use to him. just need to lower the costs because its an affront to him that some dumbass MD is making far more money than him. its an insult to his genius.

Re Mayo Clinic and Medicare, it appears that Mayo Clinic accepts Medicare for inpatient hospital stays (Medicare Part A), but not for outpatient physician services (Medicare Part B). See http://www.mayoclinic.org/billing-rst/#medicare This does not mean that Medicare Part B does not accept Mayo Clinic; just means financial responsibility for payment is on the patient and Medicare may reimburse the patient for some or all of that, but Mayo Clinic wants no part of the process other than submitting forms that may or may not get the patient reimbursed. So here you have what is often touted as model in care and efficiency not agreeing to rates set by Medicare. What facilities accept rates set by Medicare without patients having to pay extra? and how does this differ from NHS system in UK? I just can't wrap my head around how Steve's dream would work because it seems UK system may well be headed back in direction of US system.

nyc1234 - Glad you are back in the discussion. The more I read, the more I see your point about hospitals gaining more bargaining power vis-a-vis insurers such that reimbursement rates rise and premiums rise under Obamacare, thus doing nothing to alleviate the cost issue and potentially exacerbating it. Is there any consensus among physicians about best way to go? Or if not physicians in general, what about radiologists? Do specialties within medecine have distinct lobbies? Which, if any, physicians are "winning" under Obamacare?

@novice

most of the doctors right now are laughing at the idea that the hospitals will "cut the costs". so far, any close friend of mine selling a practice to the hospitals has received a nice amount of cash for the sale, a cushy salary (most of the time it has been more than what they were making previously) and decreased work hours. the hospital can do this because now the doctor is getting hospital rates so revenue doubles or triples on day 1.

however, this is prob only the 5-6th inning. the end game, in theory, is that the patients become capitated. if the avg cost per pt is $8k, then medicare and the hospital CEOs will have to trim that number. the CEOs have the upper hand here. if medicare NYC goes to the 2-4 hospital systems that are left and says we give u $6k per yr per patient and the CEOs say no, then ultimately medicare will budge or otherwise the medicare patients won't have any care. there won't be 10,000 players/doctors left competing for medicare work, there will be 2-4 "chosen" private equity companies competing for a govt contract. these groups will know what the others are bidding. in fact, i wouldn't be surprised if they are all brought to the table at the same time.

the other thing the CEOs can do is say, ok we will take $6k per person, but this will impact our margin, so we will fire 30% of the workforce. i was involved in a similar negotiation a while back. u better believe every state & city representative will be called to ask for "support" for the union workforce when there are cuts. the deal will be tied to employment. so again they will have a very strong hand. in fact, i suspect (and others do too) that the capitation amount will be better than what we get right now. right now, even though there is not complete competition, in metro markets like nyc, the payers give u whatever they want & u say yes or the guy down the street takes it. there won't be a guy down the street in this new system.

the doctors are boomers or gen x'ers. the boomers are going to quit. it's a given. they have already started leaving and made money "when it was good". that's about 50+% of the group. the gen X'ers will prob be ok with capitation as their first question is usually "how many weeks of vacation do i get". they love 10am-4pm work at 80% pay with no call. sometimes it is at 100%+ anyways considering that many practices are not good with running the business side of it and end up worst than in the hospital.

most of the specialists are going nuts prior to the hospital negotiations and generally pretty happy on the other side of it. of course, that's only the $ part. the medical part of it, the part that actually matters...well no one is happy about it. u r essentially forced to spoon feed ur patients with bullshit from the top so that they can feed their bottom line.

the solution to this problem is data. a consensus on what works and doesn't is needed (and how much this costs economically). this won't happen for a long time. in fact we are so behind technologically that there is no standardized EMR format to date. meaning if 2 doctors own EMRs and send info from one to the other, it comes out as nonsense. essentially, we don't even have a *.doc file format for medical information yet.

i despise that doctors use fee-for-service to game the system to do more when it is unnecessary. but that does not mean i love the system that CEOs will use to game the capitation system either, ie, kick the patient out the door & try to do nothing for them to pad their pockets.

Medicare Part B doesn't cover a lot.

http://www.medicare.gov/what-medicare-covers/part-b/what-medicare-part-b-covers.html

I don't think it's a big deal. May Clinic merely does not accept assignment. Not a big deal.

For once I agree with 1234, except I think capitation will be easier than he thinks - insurance companies have a limited exemption from antitrust law - which they shouldn't but that's a different matter - but hospitals don't.

@stevejhx

ok but what's ur point? what does antitrust have to do with it? if hospital A refuses the price and hospital B refuses the price, then what? would it make it better if the meetings are held separately and nothing is sinister but the number is clear as daylight anyways? or does it matter that each hospital only has a capacity to handle so many patients regardless, so, in effect, each hospital will be the monopolist in the surrounding population?

what price do u think medicare will bring to the table steve?

and did i mention that the 2 parties at the table will be:

quants

vs

govt employees

haven't we seen this match already?

This most recent back and forth has perhaps narrowed the debate down to its essence. I hate to be a pessimist, but I see U.S. taxpayer/voter/gov't employee caving every time in this scenario.

From nyc1234 post above: "the medical part of it, the part that actually matters...well no one is happy about it. u r essentially forced to spoon feed ur patients with bullshit from the top so that they can feed their bottom line."

This sounds like a quality issue that is terrifying. Aside from the worst fact that patient health could actually suffer, there could well be added costs from medmal claims. Makes me now wonder whether medmal plaintiffs' bar took a position on the ACA.

novice, medical malpractice accounts for less than 2% of healthcare costs in the US. It's a nice excuse and while it is a problem, it's by far not as serious a problem as doctors would have you believe.

1234, I never said that capitation did not come with a profit. Of course it does. It also comes with built-in controls to prevent overbilling and providing more services than necessary. And while I appreciate your deciding that such a system would not work before it's even implemented, but given the amount of waste in the system, the fact that we pay twice as much as the next closest country on healthcare on a GDP basis, and rank about #38 worldwide on the major ranking factors in healthcare, there's plenty of room to improve.

And yes I have seen the quants vs. government employees, and the government employees ALWAYS WIN.

That's why the quants are so afraid of them. Congress is a different matter, but administrative employees ALWAYS win.

That's why business is so afraid of them.

@stevejhx

so the bankers are shaking and now the hospital CEOs are as well (i know u don't live in the city but this is sarcasm, the bankers are not shaking but living pretty nicely)...

i agree something needs to be done. creating a monopolistic solution is the way to do this according to steve, who has a degree in economics (perhaps from moscow, circa '88). i notice that u are very quick to copy and paste but when given a chance to deal with the strict numbers part of it and the prediction portion of it, u get very quiet. do u want to try again? $8,7,6,5,9,10, pick a number, u r the economist.

i've laid out a very strong argument for why health care prices will likely go up significantly in this new model. i also know that financial companies are much greedier than doctors when dealing with money. the doctors that are greedy are in the minority. the financial controllers who are not greedy are in the minority.

ur response is any action is better than no action.

how about this action: why doesn't the government support a universal format for exchange of EMR information as well as a way to anonymize it so that the info can be canvassed across the country and analyzed so we can figure out what studies, tests, and procedures should be done? how about using science?

Interesting

http://vitals.nbcnews.com/_news/2013/01/09/16433458-were-unhealthier-than-everyone-else-and-its-our-own-fault?lite

btw i don't know what world u r living in, but large businesses are not "scared of the govt". GE, et al, controls the govt. not the other way around.

another sign of american doctors' failures:

http://www.nytimes.com/2013/01/10/health/americans-under-50-fare-poorly-on-health-measures-new-report-says.html?src=me&ref=general

From NYC1234: "how about this action: why doesn't the government support a universal format for exchange of EMR information as well as a way to anonymize it so that the info can be canvassed across the country and analyzed so we can figure out what studies, tests, and procedures should be done? how about using science?"

My first thought was "why isn't silicon valley all over this?" so i just did google search for "silicon valley" and "electronic medical records," and the following article was first hit: http://www.bloomberg.com/news/2011-09-23/electronic-medical-records-a-silicon-valley-gold-rush.html Is there any hope for any of these systems or are they exacerbating the problem by selling different formats and interfaces? I hope some entrepreneurial physician comes up with the winning product/system. Do all physicians want one format or is there some advantage to physicians keeping the records opaque/less than accessible?

I like this more recent article better: http://www.theatlantic.com/health/archive/2012/06/is-one-company-about-to-lock-up-the-electronic-medical-records-market/258473/

The Atlantic's article discusses different needs of large institutional players (hospital systems) vs needs of smaller, entrepreneurial players (concierge groups).

ideally every doctor wants a format where the info is easily exchangeable with each other. even if the software looks different we should be able to transfer info to each other. for ex, u can open an xls file in excel but also open it in google docs and most of it remains the same. u cannot do this with EHR.

this is the deal. with the cloud and data storage so cheap, there are inexpensive software options for EHR that are 10x more powerful and 10-100x cheaper than what the larger vendors are selling. if a company is selling u software for $100-200k + $25-$50k per year in upgrades, servicing, etc, they are not interested in seeing the smaller competitors sell u something cheaper that u can easily transfer to. they want the software to be proprietary and don't want u looking around for a cheaper options so that u can transfer all ur records at a minimal cost.

so basically once u buy the EHR u r almost trapped with it unless u r willing to pay a ton more. with PACS systems for radiology, they go a step further and usually send u a proprietary computer with the microprocessor "marked" so that u cannot upgrade or use another computer for the same job. the same thing GE was selling for $1 million can now be purchased for about $1k. of course, if u already have all of ur data in GE, to get it out of there is not cheap...so it goes.

now someone can create an EHR that would interface with ALL of the EHRs out there and sell it for cheap. but the codes are so proprietary that each new EHR link could take weeks to a month to code & many of these still require help from the other EHR vendors. there are def over 100 EHR software programs, maybe 1000. we have a software coder who works on this stuff for us but it is a SLOW process and a lot of the time the major EHR vendors will not give us any help to decode their data flow. u send data from one EHR to another, and the name shows up as the date of birth, etc. multiply this times several hundred data fields and all of the different EHRs out there. the holy grail would be a universal translator program but why would the large EHR vendors agree to this? it would kill their "moat"

"creating a monopolistic solution is the way to do this according to steve...."

If by that you mean single payer, I didn't say that it was the only way to go; I said it was one of the more efficient ways.

"who has a degree in economics (perhaps from moscow, circa '88)"

Nah. Paul Krugman has a Nobel Prize in economics and I pretty much agree with him. The problem is that the way our current system is structure there is no real competition - the government already takes on the sickest and poorest people, and the insurance companies are allowed to pick and choose among the rest. They have no incentive to keep costs low because they have been able to pass those costs directly onto their customers - the more doctors charge them, the more they can charge their customers, because we're looking at a need, not a want. Demand for health insurance is more like demand for police services than it is like demand for cars. We have the most "competitive" healthcare system in the world by far, and by far the most expensive and wasteful. The problem is that healthcare costs provably do not respond to normal market forces.

"but when given a chance to deal with the strict numbers part of it and the prediction portion of it, u get very quiet. do u want to try again? $8,7,6,5,9,10, pick a number, u r the economist."

I have no idea what you're talking about.

"but large businesses are not "scared of the govt""

Really? Then why do they spend all that money lobbying, and hire Mitt Romney as president to repeal Dodd-Frank and Sarbanes-Oxley and the Consumer Financial Protection Bureau and the Bureau of Alcohol, Tobacco, and Firearms?

if by lobbying, u mean bribing, then ok, u win. they r really scared! u do realize, regardless of their fear and hoopla in the media, that wall street is doing mighty fine, still, right? or do u think all of the derivative trades have stopped now also?

i mean pick a number that u think patients will be capitated at. if we are spending $8k+ per patient, what good will it do if the hospitals ask for $9k+ to cover the patients?

the ACOs have NOTHING to do with a single payer. it has to do with giving hospitals the ability to negotiate the rates for all medicare patients for every service. as i have said before, fine, capitate us, but don't capitate with 2-4 groups. capitate across 10,000 doctors. let us all fight to the lowest cost structure to meet the care guidelines...ie, capitalism. u r suggesting the rates should be set by a few groups as opposed to many. u r talking about capitalism but suggesting monopolies as the solution. at least now, the insurance companies control the pricing. they won't in the new system

nyc1234 - Thank you for the insight.

"Thanks for this fresh perspective Jason. I don't believe that link has been copied and pasted yet into this thread. Congrats for your quick "ctrl" skills. You were able to plagiarize this article in under 4 hrs, something even Steve can look up to."

Wow, YOU YOURSELF posted another article based on this same BRAND FUCKING NEW REPORT hours after I did, dumb shit.

...and if I plagiarized I would not have put QUOTES around what I pasted, and a url, idjut.

Very hard to resist posting what I am actually thinking. All I will say is, on the bench, at the end, with tape over the mouth.

"that wall street is doing mighty fine, still, right?"

Really you need to get out and read the newspaper more. Today's paper would be fine.

http://dealbook.nytimes.com/2013/01/09/deep-cuts-raise-questions-about-morgan-stanley/?ref=business

or maybe last month's:

http://www.huffingtonpost.com/2012/12/09/wall-street-bonuses-2012_n_2267278.html

"the ACOs have NOTHING to do with a single payer"

I never said they did, and I don't recall anybody saying they did. I said there were multiple models implemented throughout the word, from Canada's single payer system, to the UK's and Spain's mixed single-payer / private system, to France's private but tightly regulated fee-for-service system.

They are all dramatically more efficient than our system and they cost about half as much, and they deliver far better results in terms of mortality, morbidity, access to care, etc., etc. You dismiss each one of them outright based on no evidence other than "financial companies are much greedier than doctors when dealing with money."

Apparently that is only true in the United States, because it doesn't seem to be the case anywhere else. Maybe the Masters of the Universe are really smarter than all of us.

Though 2008 paints a very different picture.

The Swiss have a 100% private system, don't forget Steve. The Dutch more or less. BOTH are like Obamacare: you MUST buy insurance or be fined. The poor are subsidized. HC as a % of GDP is like 12% in Switzerland and 11% in the Netherlands versus 18% here. Both have much better health outcomes. People who ENTIRELY STUPID AND IGNORANT of how the rest of the world works are insistent on IDIOTICALLY conflating universal healtchcare with SOCIALIST health care.

Incidently, almost all UK people are under NH, so I'd put the UK squarely in the more socialist than Canada camp. But your point is correct - their are countries with LESS socialist HC than we had pre-Obama who still do it better than us. EVERYONE does it better than us among rich countries, no matter how they do it.

steve - I think the point nyc1234 was making re creating a monopolistic system is the following: The Affordable Care Act (Obamacare) is resulting in increasing concentration among the providers of healthcare. Small, independent and more efficient providers are being gobbled up by large hospital systems and hospitals are merging. This concentration is increasing the bargaining power of healthcare providers vis-a-vis both private insurance providers and the government. Once consolidation is complete, we will all be at the mercy of these large hospital systems. There will probably be enough of them that each can avoid monopolopy scrutiny; it will be more like an oligopoly, and his prediction of tacit collusion merits consideration.

>Is there any hope for any of these systems or are they exacerbating the problem by selling different formats and interfaces? I hope some entrepreneurial physician comes up with the winning product/system. Do all physicians want one format or is there some advantage to physicians keeping the records opaque/less than accessible?

Makes me think of EDI (electronic data interchange) in my industry.
Some time in the 90s,to be a Walmart vendor, you had to be EDI capable. THe system went on to be the standard for commerce with all mass merchants, drug chains, supermarket chains, etc.

Wiki can explain EDI better than I can.

"Electronic data interchange (EDI) is the structured transmission of data between organizations by electronic means, which is used to transfer electronic documents or business data from one computer system to another computer system, i.e. from one trading partner to another trading partner without human intervention.[1] It is more than mere e-mail; for instance, organizations might replace bills of lading and even cheques with appropriate EDI messages. It also refers specifically to a family of standards."

http://en.wikipedia.org/wiki/Electronic_data_interchange

That report seems to say pretty much what I was thinking. Most of what makes the US healthcare system rank so low is not entirely related to the quality of healthcare.

"Deaths before age 50 accounted for about two-thirds of the difference in life expectancy between males in the United States and their counterparts in 16 other developed countries"

"Car accidents, gun violence and drug overdoses were major contributors to years of life lost by Americans before age 50. "

"The bottom line is that we are not preventing damaging health behaviors, "

Terrible diets, sedentary lifestyle, drinking, smoking = Obesity, diabetes, heart disease. When these start to happen to younger and younger people, costs go way up and life expectancy goes down.

@jason

everyone copies and pastes. problem being in ur and steve's case, u r unable to go to the next step of logical thinking, ie the fresh perspective. all either of u have said for 860 posts is that other international systems are better than ours. failing to realize that the step we have taken will take us 1 step further from ur promise-land. i bring the fresh perspective to u by telling u what is actually happening on the ground. sure i am copying and pasting as well but i'm trying to add info on top of that. everything u 2 have stated is essentially a wiki article. u realize that wiki documents the past right?

again, what price do u envision that capitation will arrive at for the new ACO system, jason? keep copying and pasting from articles. i'm dealing with the process directly, including the conversion to the ACO system. i would love to have ur and steve's input on pricing so i can bring it to the table. i'm sure u guys have thought this through...do u guys actually think all of the info u have posted here hasn't been discussed ad nauseum by doctors, hospital CEOs, insurance CEOs, and CMS? Do u think that all of us combined haven't come to these same conclusions years (over a decade) ago?

this is a forum for people living in nyc, presumably intelligent, educated, and aware.

@steve

u sit behind the computer too much my friend. keep believing ur papers. how about u go out and meet people who are in the business instead of getting info second hand from newspapers? in fact, as u can see, the govt has done the same thing in the banking sector. they have killed competition by consolidating almost all of the power into jp & gs's hands. just wait and see how this plays out! surprise, another non-blessed bank (ms) is struggling. hmm i wonder who will save them and buy their distressed assets with a blessing from our administration.

"Though 2008 paints a very different picture."

yes it paints the picture that the bankers can't control their own derivatives (a field they are supposedly experts in)...but u seem to think they will really do well controlling health care management (a field they have no experience in)

@bob

u have hit the nail on the head. this is one of the biggest problems. of course, the idea of living healthy is antithetical to the concept that it's ur doctors' job to fix ur arteries when u r 400lbs and have triple vessel disease at age 40. as steve and jason will tell u, this is because our doctors are greedy.

if u want to compare the ACO plan to something, it would be mitt romney's tax plan. a magical idea on paper that would have solved all of our problems but devoid of any numerical details so that the bait and switch could proceed without obstruction.

I have to admit that I fell for the ACO marketing. It was not apparent to this layperson that only large hospitals would be able to achieve ACO status, but the more I read, the more it seems that this is the case. So much more to learn. The only bright spot so far is the hope that some uniform EMR system might come to the rescue.

"failing to realize that the step we have taken will take us 1 step further from ur promise-land"

There is no evidence of that, and the evidence directly contradicts "Small, independent and more efficient providers," as one of the greatest inefficiencies of the current system is a lack of coordinated care. That's pretty much universally recognized - and shared medical records are just a part of it.

"what price do u envision that capitation will arrive at for the new ACO system"

I don't think anybody has the answer to that right now, 1234. There are too many variables involved & there isn't a capitation system yet, so it's not possible to determine: we don't even know what it would look like, if it were ever implemented.

"go out and meet people who are in the business"

All of my relatives are "in the business" and they all say the same thing: they bill by procedure; if they don't do a procedure, they don't get paid. Ergo, they do procedures.

That remains the problem.

"this is because our doctors are greedy."

Did I say "doctors are greedy"? I think I didn't. I said they were responding rationally to irrational incentives. If I could do it I would, too - but I can't.

Just about no one else can - because for many reasons the healthcare sector does not respond to normal supply and demand pressures. It remains - like the police and the army and infrastructure - something that governments do far more efficiently than the private sector.

A quick glance at other OECD countries will demonstrate that.

So depressing: http://www.forbes.com/sites/aroy/2011/11/21/ftc-commissioner-accountable-care-organizations-will-likely-lead-to-higher-costs-and-lower-quality-health-care/

I am studying for my looming conversation with my favorite Republican on this topic and may end up agreeing with him. It seems to me the positive aspect of Obamacare is that we are saving the disadvantaged in society from potential bankruptcy due to catastrophic illness/accident, but it does seem the cost is going to be HUGE. I was prepared for taxes, personal insurance premiums and out-of-pocket costs to rise, but had not factored in the consolidation aspect, nor did I foresee quality of care potentially decreasing. Can anybody who supports the ACA give me some positive ammunition? I may join the camp of those who advocate the government's mandating exercise and eating healthy food.

>I am studying for my looming conversation with my favorite Republican

Just curious, how do you distinguish yourself from your favorite Republican?

HB - What do you mean? So many ways, the first of which is that I have voted blue since 1992. I was registered as an Independent when I lived in San Francisco full-time, but in DC you have to choose a side if you want to be considered for certain jobs, so I chose blue.

And on the issues?

Buy more fruit.

You don't even need to eat it all, just stuff your refrigerator full of fruit.
Throw it away before you go out of town for a week. Waste the fruit and the money spent on it.
Collect tax-payer funds which you don't require to live your lifestyle of leisure and meet your housing expenses.

Doctors are signing-up for going out on music Tours, just so they can avoid the problems associated with private practice and what nyc1234 has described in his comments on this discussion thread.

Every Tour has healthy backstage catering and free use of the gym/health-club in each hotel on the Tour.
Access to on-Tour doctors by all crew-members/Tour staff. (Non-mandated by the government.)
No waste of local hospital Emergency rooms for injuries and other health-related problems that can be attended to by the Tour doctor(s).

Oh. I would say the primary distinction is that I have a greater willingness to pay for the less advantaged in society through taxes and rely more on the government to provide services. I can understand why my favorite Republican is less inclined than I to do that; he is entrepreneurial and believes that private organizations can better meet the needs of the less advantaged. He puts both his time and his money behind his words. He is entirely self-made product of the public school system on the south side of Chicago and wants everyone to have the same chance for upward mobility in society that he had.

So, re Obamacare in particular, I do feel the need to protect the average citizen from bankruptcy due to catastrophic illness and have not heard of any better way to do this than the Affordable Care Act. While I worry about what it will do to the economy, I do believe we as a country can still afford it.

That fruit consumption preoccupation is just pitiful. As a withered up old prune you wouldn't realize that you can't force your fruit purchases on teens. If you make very good choices there will be little left over depending on the tining. But unless you have almost zero with nutritive value ( which may partially explain some things) you should clean out your refrigerator before you leave on a trip of any real duration, unless you like a skanky fridge along with your skanky life.

>Oh. I would say the primary distinction is that I have a greater willingness to pay for the less advantaged in society through taxes and rely more on the government to provide services.

But yet yesterday you said you would keep the lawsuit windfall related to ST/PCV that is clearly a reparation for misbehavior by the landlord against the less advantaged that the government subsidy was intended to support. What am I missing?

>I can understand why my favorite Republican is less inclined than I to do that; he is entrepreneurial and believes that private organizations can better meet the needs of the less advantaged. He puts both his time and his money behind his words. He is entirely self-made product of the public school system on the south side of Chicago and wants everyone to have the same chance for upward mobility in society that he had.

Sounds like an interesting guy.

>So, re Obamacare in particular, I do feel the need to protect the average citizen from bankruptcy due to catastrophic illness and have not heard of any better way to do this than the Affordable Care Act. While I worry about what it will do to the economy, I do believe we as a country can still afford it.

The average citizen, or every citizen?

>That fruit consumption preoccupation is just pitiful.

Truth, I agree that this is kind of an odd issue.

Can we please get a visit from cc tonight? What time does his meeting end?

HB - Every citizen. Re the proceeds from the lawsuit, how would my keeping those be inconsistent with my greater willingness to pay taxes to support greater government services? I recognize that were I a "better" person, I would donate such proceeds, plus a whole lot more to charity. I think I have always been on the high end of charitable giving in relation to my income, but that doesn't mean I couldn't/shouldn't give more. If you were trying to make me feel bad, you have succeeded. I am now going to make myself feel better by watching the latest installment of RHOBH - I look like a saint compared to those women. Good day, sir.

Your post ACO's says exactly what I've been saying: insurance companies have been exempted from most antitrust laws.

That must change.

And here's an answer to 1234's harping about electronic medical records:

http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html?hp

Seems the only ones to benefit were the companies that managed the systems.

Though overall EMR's are not a bad idea, there's not much surprise there.

The main problem remains the only problem that no one is talking about - fee-for-service.

And some cutting and pasting for 1234:

http://www.nytimes.com/2013/01/11/opinion/americas-health-disadvantage.html?partner=rssnyt&emc=rss

Because our system is so good, and cheap, and it's no one's fault, and it can't be fixed.

Here's a REAL study:

http://www.nejm.org/doi/full/10.1056/NEJMsb1205901

Seems like costs can be controlled.

And interesting commentary:

http://www.bloomberg.com/news/2013-01-10/medicare-must-change-even-if-its-eligibility-age-doesn-t.html

I realize there is more to it but it is pretty amazing that most of the WHO's best ranked healthcare systems are also the lowest in obesity rates. The higher the obesity almost always results in lower ranking in healthcare.

Obesity

http://www.nationmaster.com/graph/hea_obe-health-obesity

Healthcare rankings

http://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems

Steve - I like you, but your credibility is shot. I asked you for links early in the thread to give me ammunition on the "impact on the economy" front; I read them and they had no bearing on that issue. You are completely unaware of what is going on in the concierge sector of the industry; you were wrong about Mayo Clinic and Medicare; you were wrong about hospitals and antitrust; you repeatedly misunderstood nyc1234's point re consolidation and increasing concentration among providers; you continue to misunderstand nyc1234's point about whether the system can be fixed - I believe his position is that if cost-control is the goal, the current mandate is not the path to achieving that goal, and he would appear well-positioned to bring that insight. I expect you to deny the above and claim that my reading comprehension skills are flawed. Perhaps that is the case; the objective reader will simply have to judge for him/herself. With all of that said, I do thank you for being generous with your responses. I wanted someone to make the "best case" for Obamacare, and while your posts have not been persuasive for me, they have been informative. I was hoping someone else would join in on your side to assist and am disappointed that in-depth support for the mandate has not materialized on this thread.

"you continue to misunderstand nyc1234's point about whether the system can be fixed - I believe his position is that if cost-control is the goal, the current mandate is not the path to achieving that goal"

this is it.

On the positive front, there does appear to be quite a bit of common ground on the obesity issue. I have to believe that given what we achieved as a country re smoking, we should be able to get a handle on obesity.

P.S. to Steve - You also missed nyc1234's point re EMR's. Your post above re EMR's is consistent with everything he has said on that issue. Simply maddening.

"I asked you for links early in the thread to give me ammunition on the "impact on the economy" front; I read them and they had no bearing on that issue."

I have no idea what you're talking about.

"You are completely unaware of what is going on in the concierge sector of the industry"

Not much.

"you were wrong about Mayo Clinic and Medicare"

No. What I got about the Mayo Clinic was on their website.

"you were wrong about hospitals and antitrust"

No.

"you continue to misunderstand nyc1234's point about whether the system can be fixed"

No. Any suggested effort to "fix the system" is pooh-poohed by 1234.

"the current mandate is not the path to achieving that goal"

No proof of that yet because it won't take effect for another year.

"Your post above re EMR's is consistent with everything he has said on that issue."

You will note that I never said anything about EMR's until that post, unless you can find otherwise. 1234's point was that it is not possible to exchange electronic patient information which, implied by 1234, would save money. Apparently, that is not true.

ur mind is tiny

Steve - It is now definitively settled: If I ever have a question about MBS, Brooks 2 is the one I will ask. I really do love your spirit though. I have had opposing counsels like you, and they are part of what makes my work fun. Carry on.

I mean opposing counsel - no "s." Generally I don't take the time to correct my grammar or typos because I think all the grammatical errors and typos add to the flavor and highlight the lighthearted nature of the overall discussion, but I couldn't let "counsels" stand uncorrected.