Let's Talk About Health Care!

Off Topic Politics & World Issues
101

[quote]DrSkeptix wrote:

There is a line of reasoning in these threads that all pricing problems would go away if insurance disappeared, and “health consumers” were left to negotiate with “providers” in something called a “free market.”

(For purposes of discussion, I make a distinction between “medical care”–for a crisis or a chronic illness–and “health care,” variably defined.)

Let’s agree that an ideal free market depends on the open and transparent availability of information. If information is held disproportionately by sellers, buyers are at a disadvantage which cannot be bargained away.

There is NO free market in medical care for precisely this reason. Technical information is held by a few, the consumer cannot know if one doctor (or provider) is truly offering the same commodity as another, and most strongly, the consumer of services is the provider, not the patient.

(A patient cannot educate himself, in a timely fashion, in the technical merits of one diagnostic procedure or treatment over another. He is very often–not always–at the mercy of others.) The medical care market is not comparable to airflights on Priceline.com.

The parallel fallacy entertained by some, here, in “macho” style, is that they do not want to be compelled to buy insurance, or they do not need insurance because they can save and pay for it when needed. I do not intend a run through of the general theory of risk. But anyone with life experience knows that rare things nevertheless happen: meteor showers, bus crashes, colon cancer.

These are expensive events, and we are all doomed to get something, sometime, when we are least prepared. The 26 year old man I saw tonight in the ER, whom I predict will have Stage II Hodgkin’s Disease, wasn’t planning on $100,000 bill to save his life this year.

For those of you who still think you can avoid insurance premiums and save up, guess what? You will compete with the indigent for attention, and you may get the care you need, and the rest of us will foot the bill.

Medical insurance–to mitigate the risk of the unpredictable catastrophe–is absolutely necessary. “Health care plans,” not so much.

[/quote]

I’ve got a real problem with some of this, Dr. I agree that there is a great imbalance of knowledge between the producers and consumers of health care, but that’s also true of the majority of everything else we buy. Electronics is one example. What has happened to remedy this imbalance are consumer advocate groups and things like “Consumer Reports” - more services have sprung up to help the consumer. Doctors could be rated under a similar system, and in fact, they are.

I’d be interested to see how much medical bills due to personal catastrophic events went down if there were no government intervention in the market. Currently, the US government pays 2/3 of all medical bills in this country through Medicare and Medicaid. Would this guy’s Hodgkin’s Disease have cost him as much if the government wasn’t tampering with the normal supply and demand curves of health care? I don’t see how you can say that it wouldn’t since it hasn’t been tried in the past 40 years. Government spending on health care and rising costs of care are highly correlated and have been for the past 40 years. That may mean causation.

Personally, with Obamacare a certainty at this point, I’m going to start looking at medical tourism. The fine print in the current bill calls for more affirmative action doctors and (yes), most of us will be forced onto Obamacare eventually, and businesses will absolutely be dumping their workers onto it:
http://www.cato.org/pub_display.php?pub_id=10367

102

[quote]Tiribulus wrote:
Lemme ask you 2 questions before I respond further.

How would your “utility” model escape the pitfalls inherent in any other collectivist model? Assuming I’ve understood it correctly which leads me to my next question in a minute. Unless people suddenly develop an irresistible heretofore unknown philanthropic propensity, why would anybody want to be a doctor anymore with the unavoidably fixed pay scales that would follow for instance?

Second, is there a reason for your seemingly cryptic treatment of what you do see as the best solution?

You appear to be decrying socialized medicine on one hand and declaring the inevitable nature of it’s treatment as social welfare on the other.[/quote]

“Collectivist” refers to a unity of thought and opinion based on group thought and opinion. I think you mean “socialist.”

103

Looks like some Bluedogs have agreed to some shit on this bill.

104

[quote]PRCalDude wrote:
Tiribulus wrote:
Lemme ask you 2 questions before I respond further.

How would your “utility” model escape the pitfalls inherent in any other collectivist model? Assuming I’ve understood it correctly which leads me to my next question in a minute. Unless people suddenly develop an irresistible heretofore unknown philanthropic propensity, why would anybody want to be a doctor anymore with the unavoidably fixed pay scales that would follow for instance?

Second, is there a reason for your seemingly cryptic treatment of what you do see as the best solution?

You appear to be decrying socialized medicine on one hand and declaring the inevitable nature of it’s treatment as social welfare on the other.

“Collectivist” refers to a unity of thought and opinion based on group thought and opinion. I think you mean “socialist.”
[/quote]

I was using it as a general contrast to individuality.

[quote]PRCalDude wrote:
Government spending on health care and rising costs of care are highly correlated and have been for the past 40 years. That may mean causation.[/quote]

That and the escalating role of insurance itself in the equation. I am not convinced that there was no possible route where necessary treatments would remain within the financial reach of gainfully employed productive citizens of the United States without pooled resources whether in the form of insurance or social welfare.

To embrace this view is to simply say that the eventual cost in any case whatsoever would as an ipso facto consequence of technological progress require pooled resources making it an inescapable socio economic law.

I say that only appears to be the case now because it’s been branded on our minds through experience. If neither insurance nor social welfare existed, like, say Leprechauns, and had never even been attempted we would have found a way. As it is we’ll never even try anymore because we just accept that some people must pay other people’s bills.

105

After a particularly violent back/bi’s/abs workout, I’m siting here with my eyeballs dangling on my cheeks, drenched in sweat, gasping for breath, wondering why the socialists haven’t figured out a way for somebody else’s work to turn into my muscle.

Naaah, wouldn’t be the same.

106

[quote]PRCalDude wrote:
DrSkeptix wrote:

There is a line of reasoning in these threads that all pricing problems would go away if insurance disappeared, and “health consumers” were left to negotiate with “providers” in something called a “free market.”

(For purposes of discussion, I make a distinction between “medical care”–for a crisis or a chronic illness–and “health care,” variably defined.)

Let’s agree that an ideal free market depends on the open and transparent availability of information. If information is held disproportionately by sellers, buyers are at a disadvantage which cannot be bargained away.

There is NO free market in medical care for precisely this reason. Technical information is held by a few, the consumer cannot know if one doctor (or provider) is truly offering the same commodity as another, and most strongly, the consumer of services is the provider, not the patient.

(A patient cannot educate himself, in a timely fashion, in the technical merits of one diagnostic procedure or treatment over another. He is very often–not always–at the mercy of others.) The medical care market is not comparable to airflights on Priceline.com.

The parallel fallacy entertained by some, here, in “macho” style, is that they do not want to be compelled to buy insurance, or they do not need insurance because they can save and pay for it when needed. I do not intend a run through of the general theory of risk. But anyone with life experience knows that rare things nevertheless happen: meteor showers, bus crashes, colon cancer.

These are expensive events, and we are all doomed to get something, sometime, when we are least prepared. The 26 year old man I saw tonight in the ER, whom I predict will have Stage II Hodgkin’s Disease, wasn’t planning on $100,000 bill to save his life this year.

For those of you who still think you can avoid insurance premiums and save up, guess what? You will compete with the indigent for attention, and you may get the care you need, and the rest of us will foot the bill.

Medical insurance–to mitigate the risk of the unpredictable catastrophe–is absolutely necessary. “Health care plans,” not so much.

I’ve got a real problem with some of this, Dr. I agree that there is a great imbalance of knowledge between the producers and consumers of health care, but that’s also true of the majority of everything else we buy. Electronics is one example. What has happened to remedy this imbalance are consumer advocate groups and things like “Consumer Reports” - more services have sprung up to help the consumer. Doctors could be rated under a similar system, and in fact, they are.
[/quote]

First off, welcome back!

On consumer choice: last weekend I had to shop for backup laptop. I looked at specifics, got a rough idea, bought something. But computers now are commodities; pretty much all alike, within ranges.
Doctors are rated, and the rating systems are useless for the consumer for many reasons. MDs are atttached to systems, hospitals, radiologists, colleagues. There services simply are not commodities in the same sense that applies to consumer electronics and mechanics.

Well, ok, let’s assume you have chosen a doctor–or even a hospital system–based on internet rating. (Very few insured people actually have a choice in the matter, but that is a separate discussion.) Does the rating apply equally whether you have hypertension or brain cancer? You can choose based on what you need now, but what about the unforseen? Is price the only criterion, and if so, how do you know you are buying the same product?

Sorry, I cannot unscramble that egg.
People in catastrophic situations have no bargaining power, so the “free market” does not exist for them.
My point about MediCare and cost inflation is this: capital was provided where there was none, and services and technology followed. Of course, in 1965, they threw in dialysis for chronic renal failure; after all, there so few patients, how much could it cost? Well, dialysis services mushroomed, and rationing ended for the elderly, and for the young as well.
LBJ predicted that MediCare would not cost more that $4 billion per year; it now costs $400 billion or more.

As for the man with Hodgkin’s disease–he was a veteran, but was told by the nearby VA Hospital that he could not have even his first appointment until November. Well, I saw him, got his biopsy–I was right, of course–and I will have him completely studied and under way within this week.
The care he gets will be pricey–and I am such a bargain!–but the care he gets will be different than that which was available in 1965, 1985, or even 1995. Without government funds and the technology which it supports, I might argue, the quality of his care would not be obtainable at any price.

107

[quote]pat wrote:
This about sums up the bazillion problems with obamacare:

The budget figures are hair curling.[/quote]

Oh! I wish I had hair to curl!

108

[quote]Tiribulus wrote:
PRCalDude wrote:
Tiribulus wrote:
Lemme ask you 2 questions before I respond further.

How would your “utility” model escape the pitfalls inherent in any other collectivist model? Assuming I’ve understood it correctly which leads me to my next question in a minute. Unless people suddenly develop an irresistible heretofore unknown philanthropic propensity, why would anybody want to be a doctor anymore with the unavoidably fixed pay scales that would follow for instance?

Second, is there a reason for your seemingly cryptic treatment of what you do see as the best solution?

You appear to be decrying socialized medicine on one hand and declaring the inevitable nature of it’s treatment as social welfare on the other.

“Collectivist” refers to a unity of thought and opinion based on group thought and opinion. I think you mean “socialist.”

I was using it as a general contrast to individuality.

PRCalDude wrote:
Government spending on health care and rising costs of care are highly correlated and have been for the past 40 years. That may mean causation.

That and the escalating role of insurance itself in the equation. I am not convinced that there was no possible route where necessary treatments would remain within the financial reach of gainfully employed productive citizens of the United States without pooled resources whether in the form of insurance or social welfare.

To embrace this view is to simply say that the eventual cost in any case whatsoever would as an ipso facto consequence of technological progress require pooled resources making it an inescapable socio economic law.

[/quote]

In most cases, increasing technological progress means lower costs for everyone. That’s true in pretty much every industry. Only in medicine (we’re told) is this not the case. That’s pretty tough story to swallow, if you ask me.

109

[quote]orion wrote:
DrSkeptix wrote:

(Can government do this? Not well. The Democrats occasionally indicate that MediCare (and the VA) are “efficient;” i.e., they run with an overhead of 3% on services. This is a fallacy: MediCare does this at the expense of real efficiency; they “allow” ridiculous inefficiencies and fraud and waste because to police the system would cost money.)

Thank you, I hate that argument too.

Oh, the overhead of the Austrian system is just one fifth of one percent…

No fuckers, a bed in a public hospital costs twice as much as in a private institution. I hate it when people fall for the cheapest of accounting tricks. It is not even a trick really-

[/quote]

I know nothing of the Austrian national health service, but you could certainly inform us.

Overhead–and general costs–can also be low because there has been “prior rationing.” An individual may not know that something has been denied him if the technology or facility doesn’t exist for him. For example, the UK has terrific neurologists. Neurology was cheap, because treatments are few and expensive ones are not allowed. Further, my medium-sized city has more MRI machines, Cyberknife and radiotherapy facilities (for the treatment of brain tumor and aneurysm) than all of Great Britain.

I do not argue that quality is necessarily better because of technology or access.
But I can tell you that Natasha Richardson died needlessly after a skiing accident, in an airplane in the sky over Quebec, because there was no CT scanner at an emergency hospital (the nearest one was a mere 2 hrs away), no doctor who could drill burr holes. But Canadians may just think that this is just bad luck, and not a conscious decision to restrict access to acute medical care by their governments.

110

[quote]PRCalDude wrote:
Tiribulus wrote:
PRCalDude wrote:
Tiribulus wrote:
Lemme ask you 2 questions before I respond further.

How would your “utility” model escape the pitfalls inherent in any other collectivist model? Assuming I’ve understood it correctly which leads me to my next question in a minute. Unless people suddenly develop an irresistible heretofore unknown philanthropic propensity, why would anybody want to be a doctor anymore with the unavoidably fixed pay scales that would follow for instance?

Second, is there a reason for your seemingly cryptic treatment of what you do see as the best solution?

You appear to be decrying socialized medicine on one hand and declaring the inevitable nature of it’s treatment as social welfare on the other.

“Collectivist” refers to a unity of thought and opinion based on group thought and opinion. I think you mean “socialist.”

I was using it as a general contrast to individuality.

PRCalDude wrote:
Government spending on health care and rising costs of care are highly correlated and have been for the past 40 years. That may mean causation.

That and the escalating role of insurance itself in the equation. I am not convinced that there was no possible route where necessary treatments would remain within the financial reach of gainfully employed productive citizens of the United States without pooled resources whether in the form of insurance or social welfare.

To embrace this view is to simply say that the eventual cost in any case whatsoever would as an ipso facto consequence of technological progress require pooled resources making it an inescapable socio economic law.

In most cases, increasing technological progress means lower costs for everyone. That’s true in pretty much every industry. Only in medicine (we’re told) is this not the case. That’s pretty tough story to swallow, if you ask me. [/quote]

If you are having trouble swallowing, we can order a cine-esophagram, an endoscopy and H.pylori stain on your biopsy. Each of these has become cheaper over the last 10 years.
But the technical progress in treatment,say, of esophagitis, or of esophageal cancer, has become more nuanced and more focused and, well, better. It is not the same product that you could buy 10 years ago, at a “cheaper price.”

111

Thanks!

This applies to most service industry professionals.

I’m sure entire service industries could spring up to answer these questions for consumers. Doctors retiring from practicing medicine could be hired by these industries to research other doctors and provide consumer advice for a fee.

I could think of several ways in which it could exist. I bet there’s a ton of money wasted in ER care simply because the government requires hospitals to treat everyone who comes in, regardless of whether or not they have an actual emergency. You said that the majority of health costs come in at the end of life. I guarantee that under Obama care, services those at the end of life will be rationed like they are in Europe. A lot of people are kept alive when they have no expectation of a meaningful existence after care is rendered. In short: the government is mandating and subsidizing waste.

I don’t see why government funds are necessary. Capital expenses (technology) are funded just fine in every other business if the business decides that they’re necessary. If a particular business can’t afford them, they don’t buy them. If they buy them, and then can’t make ends meet, they go bankrupt and the capital goods are sold at auction to another startup looking to pick up cheap tech. At the last startup I worked for, we used equipment from the 1980s that worked just fine for our purposes to develop technology for the 2010s.

I think the medical industry is too infatuated with new whizbang tech that yields little, if any, marginal benefit over old tech. Long term dialysis is but one example. Chronic kidney disease is a death sentence, like it or not. You may be able to live longer with a dialysis treatment, but your quality of life suffers enormously.

I think I’d just prefer to die rather than cling to a miserable existence and cost everyone a fortune in the process.

112

[quote]DrSkeptix wrote:

If you are having trouble swallowing, we can order a cine-esophagram, an endoscopy and H.pylori stain on your biopsy. Each of these has become cheaper over the last 10 years.
But the technical progress in treatment,say, of esophagitis, or of esophageal cancer, has become more nuanced and more focused and, well, better. It is not the same product that you could buy 10 years ago, at a “cheaper price.”[/quote]

Are you telling me a patient can’t legally consent to a 10-year-old (but cheaper) cancer treatment over the state-of-the-art?

113

[quote]PRCalDude wrote:
DrSkeptix wrote:

If you are having trouble swallowing, we can order a cine-esophagram, an endoscopy and H.pylori stain on your biopsy. Each of these has become cheaper over the last 10 years.
But the technical progress in treatment,say, of esophagitis, or of esophageal cancer, has become more nuanced and more focused and, well, better. It is not the same product that you could buy 10 years ago, at a “cheaper price.”

Are you telling me a patient can’t legally consent to a 10-year-old (but cheaper) cancer treatment over the state-of-the-art? [/quote]

Good question.
Where there is no difference in outcome, of course. It is offered as a choice.
But what if there is a difference in outcome?

Leave out the question of malpractice liability. Leave out that outmoded older technology may not even be available as a choice.
I don’t think I can offer an inferior option in good faith. The balance scales of life versus money are heavily imbalanced.

As an extended example, take that vet with Hodgkin’s Disease.
I might waive all my fees, as I do with vets and firefighters, but there are procedures and medicines which are out of my control. We could agree on inferior diagnostic technology, if I could find it, but with inferior information comes more doubt as to the choice of effective therapy. If I offer outdated therapy as well, there may be a higher risk of recurrence and death. For example, if I chose 1985 standards of care for his HD, he might have 70% chance of cure, and an additional chance of salvage at recurrence of 10% (80% at 5 years). In 2009, the figures are more like 85% and salvage of a further salvage of 7% (92% at 5 years). He has a 5 year old daughter and another baby on the way.

OK, then, what is the marginal value of additional 12% chance of being alive, for him?
What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

114

[quote]DrSkeptix wrote:
But what if there is a difference in outcome?
[/quote]

That’s a decision the patient has to make. Ultimately, no one lives forever no matter how good the care is, right?

Sure you can. You have to inform the patient that treatment X is inferior to treatment Y, but a fraction of the cost and has a certain probability of success. Some people simply aren’t as afraid of death as others. Some people will say to themselves, “I’ve lived a rich full life, and I don’t want to be a huge financial burden, so I’m going to take the lesser treatment.”

The problem is that most doctors are pretty good scientists but terrible businessmen. At least, all the ones I’ve talked to. You can’t find older diagnostic technology probably because you guys are chucking it in the trash rather than selling it. Engineers get rid of all their old tech through ebay.

As an aside, I recently read a study linked on Eric Cressey’s site showing that a patient knowing his MRI results for low back pain actually worsened the outcome of his/her treatment.

So can we see the 80s costs vs. the 2010s costs here? Did the patient have that opportunity? If not, why not? Why isn’t the patient allowed to choose what his care will be? We’re not all Steve Jobs where we can spare no expense for care.

I smell a business opportunity here.

115

[quote]PRCalDude wrote:
DrSkeptix wrote:
But what if there is a difference in outcome?

That’s a decision the patient has to make. Ultimately, no one lives forever no matter how good the care is, right?

…

OK, then, what is the marginal value of additional 12% chance of being alive, for him?

So can we see the 80s costs vs. the 2010s costs here? Did the patient have that opportunity? If not, why not? Why isn’t the patient allowed to choose what his care will be? We’re not all Steve Jobs where we can spare no expense for care.

What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

I smell a business opportunity here.
[/quote]

There is already plenty of opportunity for inferior medical care; I do not feel it necessary to add to the supply of it.

As for the consumer advocacy sites, they are there, and they are useless for any serious matters.

As for the costs in the 1980s—I can’t remember them, and they are not available now anyway to compare costs. But just to turn this around, you tell me what the value of 1 year of life is to a 26 year old with one 5 year old daughter and another on the way. Repeat the calculation to age 90. Then, at least I will know one half the utility equation.

116

[quote]DrSkeptix wrote:

OK, then, what is the marginal value of additional 12% chance of being alive, for him?
What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?
[/quote]

He himself of course.

Whether he does it coldly or any other way, value is subjective. He, and he alone, can answer that.

117

[quote]orion wrote:
DrSkeptix wrote:

OK, then, what is the marginal value of additional 12% chance of being alive, for him?
What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

He himself of course.

Whether he does it coldly or any other way, value is subjective. He, and he alone, can answer that.

[/quote]
No, surely this cannot be…values must be objectively knowable otherwise science can’t deal with them.

118

[quote]LIFTICVSMAXIMVS wrote:
orion wrote:
DrSkeptix wrote:

OK, then, what is the marginal value of additional 12% chance of being alive, for him?
What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

He himself of course.

Whether he does it coldly or any other way, value is subjective. He, and he alone, can answer that.

No, surely this cannot be…values must be objectively knowable otherwise science can’t deal with them.[/quote]

What, no graphs, no equations?

But all of economics is mathematics!

Blasphemy!

119

[quote]DrSkeptix wrote:
PRCalDude wrote:
DrSkeptix wrote:
But what if there is a difference in outcome?

That’s a decision the patient has to make. Ultimately, no one lives forever no matter how good the care is, right?

…

OK, then, what is the marginal value of additional 12% chance of being alive, for him?

So can we see the 80s costs vs. the 2010s costs here? Did the patient have that opportunity? If not, why not? Why isn’t the patient allowed to choose what his care will be? We’re not all Steve Jobs where we can spare no expense for care.

What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

I smell a business opportunity here.

There is already plenty of opportunity for inferior medical care; I do not feel it necessary to add to the supply of it.

As for the consumer advocacy sites, they are there, and they are useless for any serious matters.

As for the costs in the 1980s—I can’t remember them, and they are not available now anyway to compare costs. But just to turn this around, you tell me what the value of 1 year of life is to a 26 year old with one 5 year old daughter and another on the way. Repeat the calculation to age 90. Then, at least I will know one half the utility equation.[/quote]

I can’t calculate your patient’s utility curve for him. But neither the government nor the insurance companies should be allowed to either. It should be his decision. I’m not even saying giving him the best care is a bad thing. I’m just trying to illustrate that, like it or not, there are hard economic realities we’re up against. There just isn’t a magic pile of money from which we can give everyone everywhere the best care all of the time. We’ve been running the money printing presses enough as it is lately.

The reality is, poorer people get poorer care than richer people regardless of whether or not we want it. No one here is talking about giving poorer people 17th century care. We’re talking about having the option of choosing care that is pretty darn good vs. state-of-the-art based on price. As technology improves, the choice becomes less and less difficult.

I think the fact that you can’t tell me where you’d even buy older tech is a huge problem. In every other industry where capital goods are purchased, you can buy old stuff for a fraction of the price of new stuff and still do a lot with it.

120

[quote]PRCalDude wrote:
DrSkeptix wrote:
PRCalDude wrote:
DrSkeptix wrote:
But what if there is a difference in outcome?

That’s a decision the patient has to make. Ultimately, no one lives forever no matter how good the care is, right?

…

OK, then, what is the marginal value of additional 12% chance of being alive, for him?

So can we see the 80s costs vs. the 2010s costs here? Did the patient have that opportunity? If not, why not? Why isn’t the patient allowed to choose what his care will be? We’re not all Steve Jobs where we can spare no expense for care.

What “free market” practice, which internet consumer advocacy site, can answer that question, coldly and fairly?

I smell a business opportunity here.

There is already plenty of opportunity for inferior medical care; I do not feel it necessary to add to the supply of it.

As for the consumer advocacy sites, they are there, and they are useless for any serious matters.

As for the costs in the 1980s—I can’t remember them, and they are not available now anyway to compare costs. But just to turn this around, you tell me what the value of 1 year of life is to a 26 year old with one 5 year old daughter and another on the way. Repeat the calculation to age 90. Then, at least I will know one half the utility equation.

I can’t calculate your patient’s utility curve for him. But neither the government nor the insurance companies should be allowed to either. It should be his decision. I’m not even saying giving him the best care is a bad thing. I’m just trying to illustrate that, like it or not, there are hard economic realities we’re up against. There just isn’t a magic pile of money from which we can give everyone everywhere the best care all of the time. We’ve been running the money printing presses enough as it is lately.

The reality is, poorer people get poorer care than richer people regardless of whether or not we want it. No one here is talking about giving poorer people 17th century care. We’re talking about having the option of choosing care that is pretty darn good vs. state-of-the-art based on price. As technology improves, the choice becomes less and less difficult.

I think the fact that you can’t tell me where you’d even buy older tech is a huge problem. In every other industry where capital goods are purchased, you can buy old stuff for a fraction of the price of new stuff and still do a lot with it. [/quote]

And if we tried to give everyone the kind of care the good doc is capable of providing he would eventually go out of business and thus the overall “utility” of society is reduced.

Either that or the good doc is forced to take on more patients at less pay and he gets to keep his business at the expense of the quality of care provided. The utility of society is still reduced.