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Our Next President?

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  • Re: Our Next President?

    the problem with standardization is that most treatments involve an n of 1. some procedures should be pretty standardized, although i suppose one practitioner might be more thorough and diligent than another in performing a pap smear, and one path lab may be of higher quality- hard to judge. medicare went to reimbursement for drg's- diagnostic related groups. didn't matter what you did- you were paid a set amount for treating condition x. of course this incentivizes choosing the most highly compensated diagnosis, not necessarily the most accurate one.

    btw, doctors are not allowed to talk to one another about their pricing - it's illegal, a violation of antitrust law. if i talk to a friend about my fees i'm committing a crime, because we might gang up on blue cross or aetna.

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    • Re: Our Next President?

      Originally posted by jk View Post
      the problem with standardization is that most treatments involve an n of 1. some procedures should be pretty standardized, although i suppose one practitioner might be more thorough and diligent than another in performing a pap smear, and one path lab may be of higher quality- hard to judge. medicare went to reimbursement for drg's- diagnostic related groups. didn't matter what you did- you were paid a set amount for treating condition x. of course this incentivizes choosing the most highly compensated diagnosis, not necessarily the most accurate one.

      btw, doctors are not allowed to talk to one another about their pricing - it's illegal, a violation of antitrust law. if i talk to a friend about my fees i'm committing a crime, because we might gang up on blue cross or aetna.
      Yeah, you're right. This is what I meant before when I said we tried every combination of cost-saving scheme imaginable. It's not just on the patient side. It's also on the doc side. And on the insurance side. None of them ever bring costs down. I mean, we've tried literally everything BUT even more complicated nonsense. There's a whole CMS innovation center now just for trying pilots on weird combinations of incentives. Nothing ever works particularly well. And even if something seems to, the effects wash out after the short term.

      Ultimately, I see it all sort of like May's Trilemma to keep it topical and up with the news.

      You've got 3 motives. Sometimes they're aligned, sometimes they're conflicting. But they conflict in predictable ways.

      1. You've got maximum profit on one hand.
      2. You've got maximum health outcomes on the other.
      3. And you've got efficient pricing on the third.

      No matter how convoluted and complex we make the system, there's no way around the inherent conflict in meeting all three of these goals simultaneously. This is why the American system cannot and does not work at the core. Basically, we've settled for decades on the idea that the above list is in priority order, and we can pretty much just ignore 3, so long as we pay lip service to it. The result is runaway costs, middling health outcomes, but the most valuable healthcare sector in the world by far, both in raw terms and as a percentage of the economy as a whole.

      Last edited by dcarrigg; 02-19-19, 10:44 AM.

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      • Re: Our Next President?

        Originally posted by dcarrigg View Post
        I tried to explain the process in broad strokes with my numbered list before. Medpac (The Medicare Payment Advisory Commission) is the legislative independent advisory commission made of private practitioners which recommends rates. CMS staff consults with Medpac staff and takes rates and rate policy under advisement. CMS then takes the NHED account survey data of provider rates paid to private insurers. The rulemaking process takes both these factors and public comment into account. Eventually a proposed rule comes out. Medpac comments again, something like this. They tinker again. Eventually, final rules are published in the fed register and set. Then providers decide whether or not they will accept Medicare, and negotiate all sorts of details, and get to recommend a number of their own adjustments and accounting methodologies, as broadly outlined in the provider reimbursement manual. Eventually a contract is signed. Even after this, providers have some flex to affect rates.

        So maybe you take issue with how I used the term 'negotiate.' It's not a free for all where a hospital CEO sits on one side of the table and a CMS bureaucrat sits on the other and they haggle rates. But neither is it an adversarial process in which a commission rules on rates and the government defends ratepayers against providers. The reality is different than either of those. The federal government doesn't just set rates. Industry has a huge role in the process, including the opening salvo out of medpac that sets the baseline for the process which I suppose I'm calling negotiation and you don't feel justifies the term. That's fine. Just a semantic quibble. Two points are that 1) providers don't have to accept Medicare at all, and, 2) there are a lot of ways they can push for and work to get reimbursed at higher rates. Hospitals also negotiate cost rates on the NIH and HHS and research side, sometimes as negotiated indirect cost rates (icrs), other times as lump sums.

        It's very convoluted. I can get deeper in the weeds, but I don't think it will be very helpful. The physician fees are separate from the facility fees, equipment fees, pharma fees, etc. But if you want to see an example of the rule governing the process, here it is. If you want to understand the mechanics of pricing better, you can play with the fee scheduler. You'll have to know something about HCPCS codes. Suffice it to say pick a letter followed by 4 numbers. So P3001 is a pap smear, for instance. So there's the base. But notice the mods by locality and MAC (Medicare Administrative Contractors, which are private intermediary entities), RVU (relative value units), various status and payment policy indicators, professional and technical components, etc. So roughly this is a broad sense of one side of the Part A and B payments. Part C payments are effectively de facto tied to percentages of the A & B amounts for various convoluted reasons, but are still independently negotiated between providers and private insurers that offer the plans. Part D we all know can't really negotiate with drug companies.

        But the whole mess amounts to one simple take-away: It's not like thinking of the federal government as a monolithic price-setting entity is helpful here. Even if one were to do so, it's not clear that the federal government in that case would be either interested in setting rates itself, nor interested in controlling costs, nor firmly on the side of consumers against providers. If anything, the process is heavily run by outside industry, in terms of the role of outside advisory rate recommendations, and in terms of the process requiring private sector negotiated insurance payment rates as input, and in terms of the relative flexibility providers have in negotiating with CMS for various determinations and adjustments that affect ultimate reimbursement rates via contracts. I realize I'm being vague here. I'm also honestly getting a bit out over my skis, as I've never participated in the process directly myself. Regardless, here's a flowchart of the provider reimbursement process even after rate rules are promulgated and contracts are signed by providers to accept Medicare that shows you the effects of some of the post-contract determinations and adjustments I'm talking about.
        All of this because you can't just admit the obvious fact that the federal government controls Medicare pricing?

        Congress has the Comptroller General appoint 17 people to a committee that makes non-binding recommendations and you describe this as the hospitals being able to negotiate rates? You can say it's a semantic quibble, but I disagree.

        In another context, you would find this laughable. Imagine a union who "negotiates" by having the CEO of the company appoint a committee, who then advises the Board, who then decides in their sole discretion how much to pay the workers. And the union members can individually accept the terms or quit. But they can't talk to each other about what they will accept or they are guilty of price fixing. And the company controls half of the jobs in that industry locally and nationally. Would you say the workers are negotiating their salary?

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        • Re: Our Next President?

          Originally posted by DSpencer View Post
          All of this because you can't just admit the obvious fact that the federal government controls Medicare pricing?

          Congress has the Comptroller General appoint 17 people to a committee that makes non-binding recommendations and you describe this as the hospitals being able to negotiate rates? You can say it's a semantic quibble, but I disagree.

          In another context, you would find this laughable. Imagine a union who "negotiates" by having the CEO of the company appoint a committee, who then advises the Board, who then decides in their sole discretion how much to pay the workers. And the union members can individually accept the terms or quit. But they can't talk to each other about what they will accept or they are guilty of price fixing. And the company controls half of the jobs in that industry locally and nationally. Would you say the workers are negotiating their salary?
          It would be more like having the board of directors appoint a committee of union members to draw up the first cut at suggested salary rates, then letting HR take that under advisement, then letting HR survey market pay rates for the job, then having a public comment period about salaries in which workers' concerns were heard, then drawing up draft salary rates, then letting the union board chime in again, then allowing workers to bill and account for their time in a variety of complex ways that let them game their salaries up after they sign the contract.

          Maybe that's not a negotiation in the pure sense. But it's way closer to it than a CEO just dictating what a job pays. And I'd bet you dollars to doughnuts that wages would be higher and increase every time you went through this process if you were to attempt it today.

          That's all I'm saying. So fine, I'll concede the point. Maybe it's not a negotiation in the strict sense. But neither is it rate setting with the intention on controlling costs. If it were, presumably costs wouldn't go up like they do, and healthcare costs might have otherwise stayed as flat as wages.

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          • Re: Our Next President?

            During 2001 I sat beside another airline traveler who told me he was concerned that his daughter was not planning to become either a doctor or a banker, but instead was determined to become an archeologist. Now I fully understand why he was so concerned.
            Last edited by Chris Coles; 02-20-19, 03:09 AM.

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            • Re: Our Next President?

              Originally posted by Chris Coles View Post
              My understanding is the very best pace to go, high quality for moderate costs for surgical work is Thailand and for dental, Hungary.
              Medical tourism is alive and well and expanding in Thailand. New hospitals are being built with different grade hotels next to them. There is an ongoing debate about how much if any this siphons off from the healthcare of the general public. A colonoscopy is still less than 500 dollars, a filling less than 50, and although big pharma is flexing its muscles, many drugs are still 1/10th the cost in the US. In addition, most drugs do not require a prescription eliminating repeated doctor's visits. Hospitals post prices and compete on basic services like complete physicals, stress tests, mamograms. Pharmacies have sales and prices are often negotiable. Surgery like knee replacements are routinely preformed by doctors trained in the US. A large majority of the younger doctors are female, refreshing in a society dominated by men. There is little pressure on doctors to quickly wrap up patient visits. In most inpatient care, the hospital handles all the paper work with your insurance company.

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              • Re: Our Next President?

                So far Warren is running on:

                — Universal day care
                — Universal health care
                — Universal income (in Green New Deal)
                — Universal jobs program (in Green New Deal)
                — Write off student loan debt
                — Civilian Disarmament aka Gun Control
                — Reparation for slavery

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                • Re: Our Next President?

                  Sounds like a plan! And a very bad one.

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                  • Re: Our Next President?

                    Originally posted by geodrome View Post
                    So far Warren is running on:

                    Universal day care
                    Universal health care
                    Universal income (in Green New Deal)
                    Universal jobs program (in Green New Deal)
                    Write off student loan debt
                    Civilian Disarmament aka Gun Control
                    Reparation for slavery
                    I'd wait at least until they get an official platform online before believing everything the media says they believe.

                    Gun control could be anything from background checks to bans. Reparations could be anything from existing affirmative action programs to fulfilling Sherman's Order No. 15. Writing off student loan debt could be anything from dropping interest rates to those the fed charges banks plus to a full blown.debt jubilee. Green New Deal means something different to everyone of them. So does "universal healthcare." You can mean universal healthcare in the Hillary sense of exactly what we have now, or you can mean it in the Bernie sense if a single payer system. Even Medicare for All means dropping the eligibility age for some, letting Medicare compete with private insurers for others, and a full blown single payer plan for still others.

                    I'll tell you one thing about Warren, though. Hate her all you want. But she's a get serious person, and all the "very serious people" know that. She's probably not gonna roll out a policy proposal that's too pie in the sky or impossible to implement. At least that hasn't been her mo since I've known her as a local senator. Is she liberal? Hell yeah. So was Ted Kennedy. That Massachusetts Senators for you. At the same time, I don't think she's coming for JimBob's Glock and taking 40 acres of his farm for reparations. The left goes on hyperbole rants that the right has taken to calling "Trump derangement syndrome." But it's no different than Obama derangement syndrome. Or pochahontas derangement syndrome. And it won't stick any better than Drumpf did among anyone but those who reside in the same echo chamber.

                    She may not even get out of first gear anyways. Her numbers in NH have been looking surprisingly weak to me. But there's a year of internet and TV ads between now and then. Just don't think it bodes well if she's polling fourth behind Harris in her own back yard. Figured she'd start in the natural top 3. So we'll see.

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                    • Re: Our Next President?

                      In the end it'll be Hillary and Bernie fighting to see who runs against Trump.

                      https://www.theamericanmirror.com/ex...-too-far-left/

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                      • Re: Our Next President?

                        She'll have a hell of a time if she hops in late and now. Especially if she thinks the party will just line up for her again. She'll be an instant front runner. But she's gonna be shunned in certain places. She'll have to pray the south falls into line for her again, because it's unlikely the big coastal cities will. And there is a lot more competition this time.

                        Rules are very different for the Dems. No winner take all like the GOP. So 20-30% might put you ahead in any given state, but maybe with only a delegate or two more than number 2. So if you really soar or flop in one region or another, it can be crucial.

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                        • Re: Our Next President?

                          Hillary would get booed off the stage almost immediately. I think Warren is "weak" in part because of the poor campaign Hillary ran. I can't put my finger why Warren = blase, Sanders equaled excitement. I think Trump will lose. No matter who the democratic candidate is, the holed-your-nose vote will be huge which is in part why so many people are running. If there was going to be a 3rd party candidate, you would have needed a lot more fever before now.

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                          • Re: Our Next President?

                            Originally posted by vt View Post
                            Sounds like a plan! And a very bad one.
                            Get with the program, vt. Gun control, reparations, infanticide and tax increase to fund giveaways to the free sh!t army is the winningest platform ever.

                            For the GOP, that is. What I want to know is who the DNC is going to blame when this dumbassery gifts the Bad Orange Man with a second term? Maybe Venezuela or Iran?

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                            • Re: Our Next President?

                              Originally posted by Woodsman View Post
                              Get with the program, vt. Gun control, reparations, infanticide and tax increase to fund giveaways to the free sh!t army is the winningest platform ever.

                              For the GOP, that is. What I want to know is who the DNC is going to blame when this dumbassery gifts the Bad Orange Man with a second term? Maybe Venezuela or Iran?
                              Always plenty of free cash to print and give away to the rich, no strings attached, though. And the infanticide thing is a laugh. How many abortions you think that orange man fathered in his time? How about all the billionaires in the Chinese rub and tug down in Jupiter? Heard they wrapped the CFO of Citigroup up in that one too. Greedy pricks got billions of dollars and girlfriends a third their age, but they still want to dump their loads into some poor sex slave who lives in a strip mall for $60 an hour. Ah, the vaunted morally superior business elite. Good thing we gave Kraft and Co billions in public money...maybe if we all dig a little deeper to give him another tax cut he'll spring for a real escort next time...
                              Last edited by dcarrigg; 02-26-19, 12:15 PM.

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                              • Re: Our Next President?

                                Originally posted by dcarrigg View Post
                                Always plenty of free cash to print and give away to the rich, no strings attached, though. And the infanticide thing is a laugh. How many abortions you think that orange man fathered in his time? How about all the billionaires in the Chinese rub and tug down in Jupiter? Heard they wrapped the CFO of Citigroup up in that one too. Greedy pricks got billions of dollars and girlfriends a third their age, but they still want to dump their loads into some poor sex slave who lives in a strip mall for $60 an hour. Ah, the vaulted morally superior business elite. Good thing we gave Kraft and Co billions in public money...maybe if we give him another tax cut he'll spring for a real escort next time...
                                I was about to ask about "Heard they wrapped the CFO of Citigroup up in that one too. Greedy pricks got billions of dollars and girlfriends a third their age, but they still want to dump their loads into some poor sex slave who lives in a strip mall for $60 an hour. Ah, the vaulted morally superior business elite." when I realised that you were not describing Citybank, as a once very good friend of mine did, as far as I know, marry into .......... someone at ~ that level.
                                (Removed the smiley as she was a very fine individual lady).

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