Health Care Discussion

[mu03eng]

(Rant warning)

We are smart people. We all took logic class. We should be able to have a discussion without trying to corner the "other side" and devolve into political posturing. That's not using logic, that's using rhetoric.

I don't know if the US has always been this politically polarized, or if I'm just old enough now to realize it. Either way, it drives me nuts, and I honestly think it's a big problem in this country.

(end of rant).

+10000000000000000000000000000000000000000

[Lennys Tap]

(Rant warning)

We are smart people. We all took logic class. We should be able to have a discussion without trying to corner the "other side" and devolve into political posturing. That's not using logic, that's using rhetoric.

I don't know if the US has always been this politically polarized, or if I'm just old enough now to realize it. Either way, it drives me nuts, and I honestly think it's a big problem in this country.

(end of rant).

I think that those truly passionate about their politics have always held beliefs that could be classified as polarized as to the role of government towards its citizens. Here's a contrast for you, though. I grew up watching guys like William F Buckley Jr and Daniel Patrick Moynihan debate every fortnight or so on PBS. Substantive, thought provoking and usually civil. Today it's Sean Hannity and Chris Matthews screaming every night in a game of "gotcha". Ubiquitous, anecdotal and angry.

[Canned Goods n Ammo]

I think that those truly passionate about their politics have always held beliefs that could be classified as polarized as to the role of government towards its citizens. Here's a contrast for you, though. I grew up watching guys like William F Buckley Jr and Daniel Patrick Moynihan debate every fortnight or so on PBS. Substantive, thought provoking and usually civil. Today it's Sean Hannity and Chris Matthews screaming every night in a game of "gotcha". Ubiquitous, anecdotal and angry.

Agreed.

I respect people's passion, but maybe it's the shouting down and dismissing of ideas that bothers me.

Debates and discussions are great, but "gotcha" stuff is sooo unproductive in my mind.

I actually like hearing both sides because I don't think there is anything to be learned by me seeking out people with my same opinion.

But, I don't want to listen to a bunch of posturing and rhetoric.

[Hards Alumni]

Agreed.

I respect people's passion, but maybe it's the shouting down and dismissing of ideas that bothers me.

Debates and discussions are great, but "gotcha" stuff is sooo unproductive in my mind.

I actually like hearing both sides because I don't think there is anything to be learned by me seeking out people with my same opinion.

But, I don't want to listen to a bunch of posturing and rhetoric.

Totally agree.  I don't watch the idiots on TV, nor do I subscribe to an entire policy of a party.

[Lennys Tap]

Agreed.

I respect people's passion, but maybe it's the shouting down and dismissing of ideas that bothers me.

Debates and discussions are great, but "gotcha" stuff is sooo unproductive in my mind.

I actually like hearing both sides because I don't think there is anything to be learned by me seeking out people with my same opinion.

But, I don't want to listen to a bunch of posturing and rhetoric.

Debates on war, enhanced interrogation, taxation, immigration, healthcare, etc., are complex. Much easier to call people "unpatriotic" for non support or scream "Blood for oil!" at the supporters. The idea that one side has a monopoly on "family values" or "social justice" is nonsensical but we have a very uninformed electorate and catch phrases and negative ads are what works on them.

[Canned Goods n Ammo]

...but we have a very uninformed electorate and catch phrases and negative ads are what works on them.

I agree 10000%, but I hope for a more intellectual approach from Jesuit-taught MU grads.

We know logic. We understand how to debate a topic without resorting to a bunch of emotional appeals and attacks.

The average American is a moron, and we have to live with that. But, we should/can expect more from an MU grad.

[tower912]

I don't hear anyone arguing that the health care system we have in the US is on the right track.   We are clearly pouring huge sums of money into it, (IIRC, the highest % of GDP of any country in the world).    It is strangling the economy just as surely as $4 a gallon gasoline.    The question is how we can get the maximum benefit for our dollar, be it getting more coverage for what we are currently paying or getting our current coverage for less.   There are ideas all over the spectrum.   But what we are currently doing clearly can't be sustained.   

[MU Fan in Connecticut]

I don't hear anyone arguing that the health care system we have in the US is on the right track.   We are clearly pouring huge sums of money into it, (IIRC, the highest % of GDP of any country in the world).    It is strangling the economy just as surely as $4 a gallon gasoline.    The question is how we can get the maximum benefit for our dollar, be it getting more coverage for what we are currently paying or getting our current coverage for less.   There are ideas all over the spectrum.   But what we are currently doing clearly can't be sustained.   

+1

6 pages of mostly civil discussion (pretty good for a what could be a sensitive subject on the Superbar) in and of itself shows the enormous complexity of the USA health care system.  I always thought that the ACA is just the start of reforming it. 

I don't hear anyone arguing that the health care system we have in the US is on the right track.  That's what always bothered me was that everyone agrees on this but seems more interested in cheap political points.  The House of Reps has voted like 40 times to repeal it.  Instead of wasting time on something that's 100% not going to happen why not offer an addition to current law that will drive down cost?

[mugrad99]

A few points I see daily ( from the hospital side of things).

Hospitals cannot survive on Medicare and Medicaid rates....especially trauma based and rural hospitals, let alone advance.

For example, Indiana has passed a new law that providers must now bill Medicaid or Medicare instead of pursuing Third Party Liability Insurance Companies. This alone will cost Indiana Hospitals hundreds of millions of dollars yearly. This money is spent to subsidize their uninsured patients, charity programs, and trauma centers. Net result, charity guidelines  (400% of poverty level) will now be reduced to 250-200% of poverty level. Those falling between 250-400% will now be sent to collection agencies, sued, and garnished.....

Med-Mal insurance is outrageous. Some states have tried to limit settlement amounts, etc, to try to curb the costs, but not enough has been done.

Who is actually making the most money out of this? My position it is the health insurance companies. Copays and deductibles are skyrocketing while premiums have gone up.

[BME to MD]

The medical equipment and pharmaceutical companies are making the largest profits and paving our road to financial hell with their continued advancement of the science.

Demand for healthcare has always been nearly infinite.  What has changed in the last 50-60 years is a profound expansion of medical science allowing medical providers to delay serious complications of chronic disease and to acutely save lives that in the past would have been beyond our capacity to save.

A good example of the paradigm is ECMO (extra corporeal membrane oxygenization) therapy which is essentially a device that takes over for a patient's heart and lung function.  Ongoing ECMO therapy requires a perfusionist (expert on the ECMO machine) to be in the hospital 24 hours a day, an ICU bed, usually 24/7 one on one nursing care, and all the other associated ICU staff (attending physician, PA/NP/resident, nutritionist, pharmacist, and cardiac or vascular surgeon to implant and monitor to blood access catheters).  ECMO is extraordinarily expensive care considering the ICU stay alone can cost >$10,000 per day.  

Since ECMO is such a resource intensive treatment most hospitals restrict its use to short term use (< 3 days in adult, < 3 weeks in neonates - it works better in neonates).  However, the bleeding edge of medical technology continnues to surge forward with the University of Maryland reporting that they kept a 24 year old patient alive on ECMO for 107 days until he could receive a double lung transplant.  

Any attempt to 'bend the cost curve' is a Quixotic mission unless it meaningfully addresses the American demand for life extension.  We cannot bend the curve with cost controls alone.

http://www.umm.edu/news/releases/world_record.htm

[dwaderoy2004]

I think that is one thing people miss.  They want Health Care to be a treated like any other market...but it just isn't the same.  If you're having a heart attack, you're not going to shop around for the best deal.  People aren't going to say "no" to a $500,000 procedure if it'll save their life.  Companies aren't evil for pursuing profits, but in the case of health care, they basically hold all the cards and can charge whatever they want. 

[WellsstreetWanderer]

In the U.S. we happen to value life and Drs. and Nurses are trained and dedicated to sustaining life. Extraordinary measures are commonly used as no one wants to be responsible for not doing their best to save a life.
I don't get why Pharma and Medical device companies are cast as the bad guys or their profits maligned. They provide a product that you can refuse to use if you like. If people knew the markup on other products( clothing for example) they would be amazed but it seems to be the Healthcare Industry that is cast as the evil entity. And virtually no one pays the inflated bill on hospitalisation, usually it is a fraction of that.

[Canned Goods n Ammo]

In the U.S. we happen to value life and Drs. and Nurses are trained and dedicated to sustaining life. Extraordinary measures are commonly used as no one wants to be responsible for not doing their best to save a life.
I don't get why Pharma and Medical device companies are cast as the bad guys or their profits maligned. They provide a product that you can refuse to use if you like. If people knew the markup on other products( clothing for example) they would be amazed but it seems to be the Healthcare Industry that is cast as the evil entity. And virtually no one pays the inflated bill on hospitalisation, usually it is a fraction of that.

Actually, I have a stupid question. (I don't work in healthcare).

Why are the prices so inflated and then negotiated down? That just seems weird/shady, doesn't it? Feels like I'm buying a used car.

I understand that insurance companies negotiate volume discounts. Makes sense.

But, the prices generally just seem super inflated to begin with.

[BME to MD]

I would like to add the caveat that healthcare workers are dedicated to sustaining life when that extension is consistent with the wishes of the patient or their surrogates. 

I for one believe that the American relationship with death powerfully shapes our national policy on healthcare and is perhaps the strongest contributor to our massive spending.

[muwarrior69]

Actually, I have a stupid question. (I don't work in healthcare).

Why are the prices so inflated and then negotiated down? That just seems weird/shady, doesn't it? Feels like I'm buying a used car.
I understand that insurance companies negotiate volume discounts. Makes sense.

But, the prices generally just seem super inflated to begin with.

Two words....risk and litigation. The malpractice debate everyone understands. No on wants to be harmed by a doctor and want to be able to sue if they are; thus high malpractice insurance. I worked in big pharma all my working career. For every drug that makes it to market 9 don't. I worked on a drug where the company spent 100 million in R&D on a particular drug only to be not approved by the FDA. Developing new drugs is a very expensive endeavor. We americans are the only citizens that pay the freight for R&D as we are the only country that does not set prices by a government.

[Canned Goods n Ammo]

Two words....risk and litigation. The malpractice debate everyone understands. No on wants to be harmed by a doctor and want to be able to sue if they are; thus high malpractice insurance. I worked in big pharma all my working career. For every drug that makes it to market 9 don't. I worked on a drug where the company spent 100 million in R&D on a particular drug only to be not approved by the FDA. Developing new drugs is a very expensive endeavor. We americans are the only citizens that pay the freight for R&D as we are the only country that does not set prices by a government.

Well, that would explain high prices, and I understand that. You make money in mass production by stamping out the same widget over and over and over. The cost of R&D goes down the more you can repeat the same thing. Drugs are always evolving, so the cost of R&D is very high (vs a frying pan).

But, why are some things priced at $30,000, and then reduced to like $5000 if you pay in cash?

My experiences are brief and limited, but it feels like I'm shopping at TJ Maxx or something.

(maybe I should go to a better hospital).

[Hards Alumni]

Two words....risk and litigation. The malpractice debate everyone understands. No on wants to be harmed by a doctor and want to be able to sue if they are; thus high malpractice insurance. I worked in big pharma all my working career. For every drug that makes it to market 9 don't. I worked on a drug where the company spent 100 million in R&D on a particular drug only to be not approved by the FDA. Developing new drugs is a very expensive endeavor. We americans are the only citizens that pay the freight for R&D as we are the only country that does not set prices by a government.

As someone who has also worked in Pharma (I don't anymore) I can say this is totally accurate, and a lot of people just don't know.  At my previous job, my group was tasked with doing the stability testing for a conversion of an adult dosage inhaler to a child dosage inhaler.  We worked on that for at least 3 years with 10 dedicated scientists working 40+ hours a week.  By the time I had left, they still had not perfected the product to a degree that it would pass the FDA regulations.  Imagine how much money was spent on this one drug alone... a drug they KNEW worked.  Simply trying to convert from adult to child dosage cost millions and millions.

[Henry Sugar]

Any attempt to 'bend the cost curve' is a Quixotic mission unless it meaningfully addresses the American demand for life extension.  We cannot bend the curve with cost controls alone.

We need Death Panels!

In all seriousness, I totally agree with this general point. My wife and I have had the conversation many times about our preference for maximizing the end quality of life vs the end quantity of life.

[mu03eng]

Well, that would explain high prices, and I understand that. You make money in mass production by stamping out the same widget over and over and over. The cost of R&D goes down the more you can repeat the same thing. Drugs are always evolving, so the cost of R&D is very high (vs a frying pan).

But, why are some things priced at $30,000, and then reduced to like $5000 if you pay in cash?

My experiences are brief and limited, but it feels like I'm shopping at TJ Maxx or something.

(maybe I should go to a better hospital).

There are multiple reasons for the inflated price.  First, medicare and medicaid don't reimburse at the "true cost" of procedures so the providers play a shell game of inflating private insurance to cover the medicare short fall.  The same thing for the uninsured, they are "covered" by the inflated prices.  There is also the malpractice premium mentioned before.

The last reason is actually financial accounting funny business because of incorrect cost accounting.  If you look at a hospital, if you were accounting for cost correctly, where most hospitals make money is services like PT, OT, pharmacy, blood lab, etc.  The surgeries themselves have the highest cost because of all of the overhead(doctors) so to make the numbers work they have to charge high prices and discount then keep costs down on the services portion even though the margins are huge.  Basically they rob the Peter(services) to pay Paul(doctors, specifically surgeons)

[Canned Goods n Ammo]

There are multiple reasons for the inflated price.  First, medicare and medicaid don't reimburse at the "true cost" of procedures so the providers play a shell game of inflating private insurance to cover the medicare short fall.  The same thing for the uninsured, they are "covered" by the inflated prices.  There is also the malpractice premium mentioned before.

The last reason is actually financial accounting funny business because of incorrect cost accounting.  If you look at a hospital, if you were accounting for cost correctly, where most hospitals make money is services like PT, OT, pharmacy, blood lab, etc.  The surgeries themselves have the highest cost because of all of the overhead(doctors) so to make the numbers work they have to charge high prices and discount then keep costs down on the services portion even though the margins are huge.  Basically they rob the Peter(services) to pay Paul(doctors, specifically surgeons)

That makes sense. In most businesses there are some loss leaders that are used to support the more profitable areas.

Thanks for the info.

[keefe]

I think that those truly passionate about their politics have always held beliefs that could be classified as polarized as to the role of government towards its citizens. Here's a contrast for you, though. I grew up watching guys like William F Buckley Jr and Daniel Patrick Moynihan debate every fortnight or so on PBS. Substantive, thought provoking and usually civil. Today it's Sean Hannity and Chris Matthews screaming every night in a game of "gotcha". Ubiquitous, anecdotal and angry.

Excellent examples, Lenny. I remember enjoying those two. I would add Gorge Will, James Kilpatrick, William Safire, Davis Broder, Ellen Goodman, and Robert Maynard to that list. The discourse could be sharp and pointed but it was always well reasoned and certainly civil.

Cokie Roberts delivered the eulogy at Betty Ford's funeral. She pointed out how bipartisan consensus was often reached when her father, Hale Boggs, had dinner with Jerry Ford. Over steaks and scotch they would find the best solution for America. If neither man could find it within himself to find that solution the wives, Lindy Boggs and Betty Ford, would help their husbands find that consensus.

The lack of civility in America is depressing. It is all the fault of those damn liberals, mind you...

[keefe]

That makes sense. In most businesses there are some loss leaders that are used to support the more profitable areas.

Thanks for the info.

Ammo,

I have not been subjected to the US medical system (non-military) for decades so my perspective on patient care and attendant costs is limited. I do have insight on drug discovery & development. I was part of the GE team that set up a JV in Singapore and Shanghai between GE, Harvard Care Group, Quintiles, and Sun MicroSystems. We established infrastructure (virtual and brick and mortar) for Clinical Trials in Asia. To get a molecule to market with regulatory approval takes a decade. The failure rate is 98%. And the investment in a molecule through Phase III approaches $1 billion. The capital required is enormous, the risks are high, and the potential for return is staggering. Drug companies build into their cost model a capital reserve for litigation as well as recovery for failed trials.

Drug discovery and development as a research imperative functions relatively efficiently. But as a business model it is beginning to break down. Unless there can be systemic or institutional relief from predatory litigation many promising molecules will never reach market. 

[ChicosBailBonds]

I think that those truly passionate about their politics have always held beliefs that could be classified as polarized as to the role of government towards its citizens. Here's a contrast for you, though. I grew up watching guys like William F Buckley Jr and Daniel Patrick Moynihan debate every fortnight or so on PBS. Substantive, thought provoking and usually civil. Today it's Sean Hannity and Chris Matthews screaming every night in a game of "gotcha". Ubiquitous, anecdotal and angry.

Agree.  I used to get a kick out of watching Buckley and others debate.  Remembering Saffire at the NY Times....they wouldn't dream of putting someone like him on those pages now. 

Lots of gotcha politics, but that has also happened for longer than people think in my view.  It's just been more subtle in the past, less in your face.  The agendas driving what was talked about, what was printed on the front page, etc, has been there for a LONG time.

But it's hardly just the media talking heads, it goes down to the grass roots, it goes into institutions themselves.  Today's IRS revelation out of Cincinnati is just another classic example of targeting....this time they were caught, how many times are these things done for intimidation purposes and they aren't caught.  Really sad.

[keefe]

I agree 10000%, but I hope for a more intellectual approach from Jesuit-taught MU grads.

We know logic. We understand how to debate a topic without resorting to a bunch of emotional appeals and attacks.

The average American is a moron, and we have to live with that. But, we should/can expect more from an MU grad.

Just a gentle reminder that Sen. Joseph McCarthy is a Marquette graduate.

[ZiggysFryBoy]

Actually, I have a stupid question. (I don't work in healthcare).

Why are the prices so inflated and then negotiated down? That just seems weird/shady, doesn't it? Feels like I'm buying a used car.

I understand that insurance companies negotiate volume discounts. Makes sense.

But, the prices generally just seem super inflated to begin with.

Most health insurance policies pay up to "usual and customary" charges.  as reimbursements drop, charges go up and "usual and customary" increases to make up the short fall.  It's a vicious circle.