Facebook exchange better than expected

This turned out to be actually substantive! Mulling a reply that isn't too stubborn.

Jim von der Heydt

Heinz, are Medicare reimbursement rates so low that they would drive you out of business? Cuz they've been set by the government for four-plus decades.

Good of you to acknowledge that tort reform is no longer a partisan issue. Obama is pursuing it, as I expected he would, although perhaps not vigorously enough. In any case there are a huge number of experts telling you that you're wrong about the systemic costs of defensive medicine. I would be willing to hear from other actuaries, but my sense of what I've read is that only a few percent of the problem could be addressed by tort reform. In any case I'm all for it.

My points about government being perfectly justified in slightly decreasing the incentives for specialists were not retracted by my second post. I continue to maintain that doctors' insistence on a laissez-faire professional world is unrealistic and civically inappropriate. ... Read More

And as to the point you addressed: I think the supposed Democrats who *disregard* the benefits of state-of-the-art medicine are straw men. Public-health policymakers should and do acknowledge those benefits but also should be and are prepared to consider them, at the margin, on rare occasions, legitimately outweighed by the social costs. This is healthier for society than the weaselly rescission and stuff that insurance companies do.

This kind of cost-benefit reasoning is also why speed limits are set higher than 30, and is not out of place in the political sphere as long as it's well infused with expertise and evidence. Sometimes I think doctors are analogous to midcentury anatomy experts stubbornly protesting that the human body can't be kept safe going any faster than 30 mph. To which we as a society might need to say, yes, thank you, we know, but we got places to go! We can't afford to maximize safety at, literally, any cost.

Please note that the rationing I seem to be advocating is in fact several removes away from any given patient, and is about long-term public-health efforts to bend the cost curve, in a way insurance companies have proven themselves utterly incapable of doing.

Pretty good for iPod typing, huh?

SB

Jurgen, that is indeed an impressive use of the Facebook app on your iPhone. It must be an extension of that talent for typing that you have always had. I can still see your fingers flying across the Mac keyboard in that closet we called the Pub Room back at CPS.

Anyhow, remember how the op piece that started this entire thread stated that "Medicare's price controls already pay only 83 cents on the private dollar?" Well, as far as the general public knows, this must apply to all specialties, and it doesn't sound so bad. Hence, you question whether I exaggerate when I state that expansion of Medicare reimbursement rates would drive my colleagues out of business.

Well, here's a dirty little secret back at you. The GAO recently looked into Medicare reimbursement rates for Anesthesiologists. What it found was that the Center for Medicare and Medicaid Services reimburses Anesthesiologists at a rate of just 33% of what the private insurers do. That's right -- 33 cents on the private dollar for a medical service that I think (as should anyone who has ever had surgery or a baby) is pretty darn vital. This amount does not come close to covering what it actually costs to provide the safe anesthetics that society demands of us.... Read More

Given that >40% of the typical Anesthesiology group's payer mix is Medicare/Medicaid, it should be obvious that it is the payments that are received for services provided to privately insured patients that allow us to provide care to all comers. Expand Medicare, which is inevitable given the aging population, or create a public option with a payment structure based on existing government rates, and watch as group after group goes under, owing to the unsustainable level of government reimbursement. So, with few Anesthesiologists left around to provide anesthetics, patients will be faced with having either nonphysicians provide their anesthetics (assuming they can sustain their practices on the 33%) or no anesthetic at all. Low-quality anesthetic means more complications. No anesthetic means no surgery. In essence, the number of safe anesthetics and operations performed would be rationed, all because society has places to go.

This is real. This is not me getting caught up in anyone's hysteria (not that I'm known to ever do so). I'm on the inside, and I see the writing on the wall. Should any reform go through that involves expansion of existing government reimbursement rates, the future of my specialty would look very bleak indeed. When I put myself in the position of my patients, I truly hope that, for the greater good, those in charge open their eyes to the not-so-implausible consequences of what they are proposing.

A Facebook exchange

To be updated as further comments come across the transom.

The link is a remarkable example of how basic political discourse has taken on the tone of extremity due to Republicans' moving the standard of what's appropriate. Even direct policy disagreement takes a Glenn Beck tone of 'they are coming to get us and NO ONE IS NOTICING IT!"

Actually, we notice it and we like it.



Facebook exchange starts with this:

SB thanks Laura for the informative link.

Obama's War on Specialists - WSJ.com

Source: online.wsj.com

The Wall Street Journal writes that ObamaCare will cut payments to specialists in favor of general practitioners because specialists perform the majority of expensive tests and procedures that cost the government money.

Comments
XX:
There you go, more damage. Great job Panch..

Laura:
You are very welcome. I want everyone in America to read this and then decide what kind of medical care they want for THEIR family and THEMSELVES. I assure you Congress will have the best care. The rest of us may not!

YY:
Being on the "other" side...this type of information is NOT known....as well as so much more. The more this is out put OUT there, the better. Thanks Panch and Dew for providing this....I will re-post.

10 hours ago

Laura:

THanks! This is the stuff that Obama is NOT telling people! The really SCARY stuf!

9 hours ago

YY:

OF COURSE he is NOT telling people! I will do what I can to spread the info you guys post.

9 hours ago

Jim von der Heydt

First of all, nobody likes Baucus's bill, largely because it was written by the insurance companies. No surprise that doctors get screwed in it, like everyone else.

But in a larger sense: can you look past your own interests for just a second? The rhetoric of war and conspiracy oozes out of this piece, and even more out of the comments. But what is violent or secret about any of this? This is the normal legislative process (and through it in the past marginal tax rates on high earners reached way above 50% -- count your blessings). Moreover, what's being debated, nonviolently and nonsecretly, is nothing less than the ability of society to manage its finances and to administer to public health.

The author acknowledges: we need more GPs. (Better minds than Baucus's would push the argument that even more we need more nurse practitioners.) So how does anyone suppose we're going to get them, if not by tweaking the incentive structure? Should there be no tools to adjust, even slightly, over a seven-plus year horizon, a market wildly distorted (as it must be) by the huge information asymmetries in the doctor-patient relationship? Remember that patients have zero option of shopping around among various oncological diagnostics.

To choose a quote at random: "Team Obama is sending a message to the medical community about its political priorities." Replace the word 'political,' which is meaningless in this sentence, with the phrase 'public-health' (hyphenated here because I'm an English teacher) and you have a sentence Americans should feel perfectly comfortable with. And yet you guys say it like it's a bad thing!

In a few weeks, after open debate on the heels of a mandate election, we'll be able to replace the phrase 'Team Obama' with 'The American people, through its duly elected representatives, and with the support and input of the AMA, the existing private insurance industry, and actuarial, finance, and public-health experts across the spectrum.". Since life is not an Ayn Rand novel, this is about the best anyone, whether an affluent specialist or (ahem) not, can hope for from a government.

4 hours ago

Jim von der Heydt

On re-reading: This is actually quite a well-written piece, compared to what's typical in the current climate. I want to single out one sentence, though, that seems especially exaggerated: "Democrats look at these advancements and see only the costs, not the benefits." Is there any basis for saying this? I think what the author actually objects to is the very idea of using cost-benefit analysis at all in public-health matters, even on the most global, actuarial/financial level. Dirty little secret: such analysis already predominates, but it intrudes into individual MEDICAL decisions rather than public-health trends. And it's done behind closed doors, with no policy goals or accountability except to executives and shareholders: in insurance companies.

I'm in favor of addressing these questions directly, openly, in the political process, on the actuarial level, instead of secretly and violently exerting financial power on the bodies of captive insurance consumers.

update:

SP:
Jurgen, mein guter Freund, I'm glad you gave this op piece a re-read. It is indeed fairly well-written, given much of the other junk that floods my computer screen on a daily basis. I think you're off in your analysis of the cost-benefit sentence. I believe the author has written what he truly feels, that in his mind, Democrats are simply looking at the costs of medical advancements and ignoring the benefits of these advancements to society.

There is a role for cost-benefit analysis in the practice of medicine, and it is not behind the closed doors of the insurance companies. Instead, it should be taking place each time one of the maligned specialists orders an expensive test or procedure. What happens, however, is that the physicians end up ordering unnecessary tests and procedures, most of which confirm what is already known or rule out what is unlikely in the first place, simply to protect their buttocks in case of lawsuits. This defensive practice of medicine has exponentially driven up the cost of health care, while simultaneously padding the pockets of hospital systems and biomedical equipment companies, forcing insurance companies to ration treatments to maintain their profit margins, and making those in power feel the need to swoop in make things right.

The Democrats do not want to take on the trial lawyers. I'm sure you're aware of the stats regarding campaign contributions -- it's obvious why it would be suicide for any politician, Democrat or Republican, to make tort reform a priority on the national level. However, take a look at what has happened in your home state. Since tort reform went into effect earlier this decade, Texas has been flooded with new physicians, both primary practitioners as well as specialists. Counties that had no PCPs nor specialists now boast multiple physicians present. Speaking for my group, we practice evidence and clinical-judgment based (I'm not sure how to hyphenate all of this) medicine rather than defensive medicine. Every session of the Texas Legislature since passage of statewide tort reform has seen numerous attempts by the trial lawyers to turn back the clock to yesteryear, but so far, our representatives have held strong. Could Texas be doing more with this cost savings to ensure health coverage for more people? Absolutely. The financial groundwork has been laid.

If those on the national scene would simply open their eyes and look at it from the perspective of those of us in the trenches, the would realize that "affluent" physicians are not the problem. We, affluent or not, are simply an easier target than the trial lawyers are. I know what it costs to do what I do. I know why the costs are what they are. I know that if it gets down to the government determining what my colleagues and I should get for our services for a larger pool of patients than exists currently, we will be driven out of business. Now, if you are the patient, is that what you really want?

I've told you this before, Jim -- I'm all for health insurance reform. It just has to be done the right way.

Jim von der Heydt:
Heinz, are Medicare reimbursement rates so low that they would drive you out of business? Cuz they've been set by the government for four-plus decades.

Good of you to acknowledge that tort reform is no longer a partisan issue. Obama is pursuing it, as I expected he would, although perhaps not vigorously enough. In any case there are a huge number of experts telling you that you're wrong about the systemic costs of defensive medicine. I would be willing to hear from other actuaries, but my sense of what I've read is that only a few percent of the problem could be addressed by tort reform. In any case I'm all for it.

My points about government being perfectly justified in slightly decreasing the incentives for specialists were not retracted by my second post. I continue to maintain that doctors' insistence on a laissez-faire professional world is unrealistic and civically inappropriate.

And as to the point you addressed: I think the supposed Democrats who *disregard* the benefits of state-of-the-art medicine are straw men. Public-health policymakers should and do acknowledge those benefits but also should be and are prepared to consider them, at the margin, on rare occasions, legitimately outweighed by the social costs. This is healthier for society than the weaselly rescission and stuff that insurance companies do.

This kind of cost-benefit reasoning is also why speed limits are set higher than 30, and is not out of place in the political sphere as long as it's well infused with expertise and evidence. Sometimes I think doctors are analogous to midcentury anatomy experts stubbornly protesting that the human body can't be kept safe going any faster than 30 mph. To which we as a society might need to say, yes, thank you, we know, but we got places to go! We can't afford to maximize safety at, literally, any cost.

Please note that the rationing I seem to be advocating is in fact several removes away from any given patient, and is about long-term public-health efforts to bend the cost curve, in a way insurance companies have proven themselves utterly incapable of doing.

Undertaking

I seem to have come up with four metaphors in the first two words of blogging. That should be enough for the first post.

Blogging means the space to explain oneself, so here are the four. The other ways I seem to need to explain myself can wait. Ultimately I hope this blog will be about other people -- but that brings me immediately to my own issue 1.

1) The metaphor of writing as a way of making more kindness: in oneself, maybe somehow in other people as well. Short version -- pronounce the blog address en-kind-ler, with a long i. If cruelty is the worst thing we do (Richard Rorty), then I should be allowed to define kindness as all the best things we do. One question is whether that can ever include polemic, of the sort that on the surface at least is UNkind. Which brings me to

2) Enkindling -- sparking fires. Making people angry. Making myself angry, by thinking about other people. Burning up, and thinking about things that burn up, the underbrush in my brain. Sweeping away ashes.

3) Getting rid of the deadwood in my brain, and the dead 'woulda coulda shouldas' I apply to myself and others. Burying the past, with dignity, with the blood still in its veins but also with just the right amount of embalming. Hence, 'undertaking,' like undertakers do.

4) Also, undertaking to be proactive with my writing, rather than just responding to the text that comes my way. The only way to begin is to begin. Planting a seed while burying a body. (And yeah, I know where some bodies are buried, but that will not be the topic of this blog.)

Twice a day, then: I undertake all these things at once. Should be plenty, without the bitterness.


Tant' e amara che poco e piu morte:
Ma per trattar del ben che vi trovai,
Diro de l'altre cose c'hi v'ho scorte.

IN ORDER TO SPEAK OF kindness, then, I might be acerbic. But I hope the acid test will always be whether kindness is being advanced.



Welcome, friends. I miss you all and hope to bemuse you and be rigorous.