Does anyone know what this is about?

[GooooMarquette]

1. Good in theory. Horrible in execution (at least currently) because:

a) EMTALA - people will still just go to an ER whenever they feel like it, rather than when appropriate.
b) "Value" is beginning to be established by consumer/patient reports, ie. when a patient is "unhappy" with their care, they fill out a survey that punishes the provider/system. So what happens? Providers are at the mercy of making the patients happy, regardless of what is best for their health.

Medicare is on the cusp of establishing value metrics, which will result in payments to the organizations being tiered based on legitimate indicators of quality.  Obama mentioned it in his speech the other night.  Lots of professional organizations have been compiling data like complication rates, survival rates, etc compared to cost.  This article from a few years ago in the New Yorker gives you an idea of what they're working on:  http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

Yes, consumers are doing the same thing, but the "consumer preference" metrics won't affect patients' preferences anywhere near as much as Medicare metrics that will directly impact how much the patient pays.  And that's probably a good thing, since most consumer preference indicators for health care show that patients realy can't distinguish good quality and value - instead, they mostly prefer docs that order more tests.

[forgetful]

Food and clothes are needs too, but haven't increased at nearly the rate of education and healthcare.  Want to guess why?  Because consumers pay directly for them.

Both of these are world-wide commodities, so it has to compete in a global market.  That alone will keep prices down.  Also, anyone can decide to make clothes or grow food, with minimal personal investment.  Healthcare and education are regulated and require a large initial investment, which allows both to operate as essentially monopolies (not the right word, but conceptually similar).

[GooooMarquette]

Both of these are world-wide commodities, so it has to compete in a global market.  That alone will keep prices down.  Also, anyone can decide to make clothes or grow food, with minimal personal investment.  Healthcare and education are regulated and require a large initial investment, which allows both to operate as essentially monopolies (not the right word, but conceptually similar).

Healthcare and education are global commodities too.  

I work for a healthcare provider that sees a significant percentage of our patients from overseas.  There are more than you think.

My daughter grew up in the US, and in the past couple of years has studied in Argentina and Cuba.  In a year or so, she'll be heading off to law school in England.  Her boyfriend (from India) studies in Minnesota, and plans to go to grad school in England.  

Everything is a global marketplace.

You don't think food is regulated by the government?  Meet the FDA.  Heard of milk and corn subsidies?

[BME to MD]

The primary driver of healthcare costs is rapidly increasing dissociation between the delta increase in life expectancy and the delta increase in cost.  The vast majority of life expectancy gains outside of the last 20 years were based on the development of hygiene, vaccines, and antibiotics which resulted in massive decreases in childhood and adolescent mortality at a very low cost.  Current advances against the mortality of organ failure and cancer are disturbingly expensive.

America is woefully ignorant of the fact that our massive health expenditures are the primary funders of biotech and pharmaceutical firms that sell the same medicines to other countries to other countries for 10 cents on the dollar because those countries have the power and resolve to get by without them if the company won't drop prices. 

It is true that globalization will provide cost pressures but only on elective procedures.  The most expensive patients (organ failure, cancer, etc) will not intentionally choose to have their end of life care overseas or frequently even across the country.

[GooooMarquette]

The primary driver of healthcare costs is rapidly increasing dissociation between the delta increase in life expectancy and the delta increase in cost.  The vast majority of life expectancy gains outside of the last 20 years were based on the development of hygiene, vaccines, and antibiotics which resulted in massive decreases in childhood and adolescent mortality at a very low cost.  Current advances against the mortality of organ failure and cancer are disturbingly expensive.

A factor - absolutely.  The primary driver - no.  The main problems are paying for services based on volume instead of results, and patients making decisions while insurers pay the bills.

[forgetful]

Healthcare and education are global commodities too.  

I work for a healthcare provider that sees a significant percentage of our patients from overseas.  There are more than you think.

My daughter grew up in the US, and in the past couple of years has studied in Argentina and Cuba.  In a year or so, she'll be heading off to law school in England.  Her boyfriend (from India) studies in Minnesota, and plans to go to grad school in England.  

Everything is a global marketplace.

You don't think food is regulated by the government?  Meet the FDA.  Heard of milk and corn subsidies?

They are not global marketplaces.  If I'm sick I can't just go to a chinese doctor at 1/10th the cost.  Similarly, if I want to get a good job, I can't just go to school in Equador to save money.  We are required to go to local doctors, the number of which (competition) is limited each year.  

Food is most assuredly regulated by the government, but subsidies there are intended to assure there are more crops being produced to lower costs.  Government regulations in healthcare and education suppress people from entering the field and suppress competition.

[forgetful]

The primary driver of healthcare costs is rapidly increasing dissociation between the delta increase in life expectancy and the delta increase in cost.  The vast majority of life expectancy gains outside of the last 20 years were based on the development of hygiene, vaccines, and antibiotics which resulted in massive decreases in childhood and adolescent mortality at a very low cost.  Current advances against the mortality of organ failure and cancer are disturbingly expensive.

America is woefully ignorant of the fact that our massive health expenditures are the primary funders of biotech and pharmaceutical firms that sell the same medicines to other countries to other countries for 10 cents on the dollar because those countries have the power and resolve to get by without them if the company won't drop prices. 

It is true that globalization will provide cost pressures but only on elective procedures.  The most expensive patients (organ failure, cancer, etc) will not intentionally choose to have their end of life care overseas or frequently even across the country.

To some extent much of this is true, especially the cost of late-life care.  I don't think medicine cost is a large driver though of healthcare costs for the average person.  It is, what I'll call predatory medicine.

An example, a friend went to his doctor, because he thought he was having an allergic reaction to a medication (he began self treating with benadryl, but needed a new medicine), the nurses immediately sent him to the emergency room (wouldn't see him there).  At the emergency room they ran every test you can imagine, before sending him home with benadryl.  Cost for him $24,000, to be told he had what he thought he had and to finally be given a different antibiotic.

Or one that happened to me, went to a doctor (a walk-in), was prescribed an antibiotic.  I forgot that I had a bad experience with that one before, so before filling it called the doctor back to ask if I could have the prescription switched.  I was told that it wouldn't be a problem, but I had to come back in and would have to pay for another office visit.  I was also once charged a $250 office visit to hear that "my tests were fine."  I had asked if I could here the test results over the phone, but they insisted I and to come in. 

[GooooMarquette]

They are not global marketplaces.  If I'm sick I can't just go to a chinese doctor at 1/10th the cost.  Similarly, if I want to get a good job, I can't just go to school in Equador to save money.  We are required to go to local doctors, the number of which (competition) is limited each year.  

Food is most assuredly regulated by the government, but subsidies there are intended to assure there are more crops being produced to lower costs.  Government regulations in healthcare and education suppress people from entering the field and suppress competition.

You may not be able to go to the Chinese doctor for acute episodes of care, but acute episodes of care are the minority in terms of $$$.  The vast majority of care (and much of the most expensive care) deals with chronic conditions - cancer, hypertension, etc.  There is nothing preventing you from going to China for these...except the disconnect between consumer and payer.  If you (instead of an insurer) paid the bill, you might very well go to China to save 90% of the cost of treatment.  Which takes us back to my post this afternoon....

[GooooMarquette]

To some extent much of this is true, especially the cost of late-life care.  I don't think medicine cost is a large driver though of healthcare costs for the average person.  It is, what I'll call predatory medicine.

An example, a friend went to his doctor, because he thought he was having an allergic reaction to a medication (he began self treating with benadryl, but needed a new medicine), the nurses immediately sent him to the emergency room (wouldn't see him there).  At the emergency room they ran every test you can imagine, before sending him home with benadryl.  Cost for him $24,000, to be told he had what he thought he had and to finally be given a different antibiotic.

Or one that happened to me, went to a doctor (a walk-in), was prescribed an antibiotic.  I forgot that I had a bad experience with that one before, so before filling it called the doctor back to ask if I could have the prescription switched.  I was told that it wouldn't be a problem, but I had to come back in and would have to pay for another office visit.  I was also once charged a $250 office visit to hear that "my tests were fine."  I had asked if I could here the test results over the phone, but they insisted I and to come in.  

Sounds like you and your friend went to the low value providers I alluded to earlier.  Read the New Yorker article.

[forgetful]

Sounds like you and your friend went to the low value providers I alluded to earlier.  Read the New Yorker article.

Except these occurred at major research University hospitals/clinics.  The McAllen model is becoming the norm.  There are very few alternatives in major metro areas in many parts of the country. 

[ChicosBailBonds]

Speaking of arms race...I got a tour of the new Oregon Ducks arena today.  Incredible facility

[BME to MD]

A factor - absolutely.  The primary driver - no.  The main problems are paying for services based on volume instead of results, and patients making decisions while insurers pay the bills.

Paying for results works if you have a uniform distribution of disease, age, compliance, frailty, socioeconomic status, etc, etc.  The Mayo Clinic is primarily a consultation (diagnosis) and surgical intervention center.  They are able to provide diagnoses and surgeries for a relatively low cost.  It is very important to realize that they are providing very little unfunded care to uninsured or underinsured individuals given their location.  Further the patients they diagnose and do surgery on do not present to their clinics or their emergency department in extremis.  Instead those patients present to their local hospitals where they receive intensive care from the moment they hit the door.  They are frequently necessarily placed on respirators, have their kidneys supplemented with dialysis, have their hearts supplemented with medications, and require 1 to 1 or 2 to 1 nursing care.  

Patients and their families haven't recently changed their preferences on avoiding death but we have massively extended our ability to facilitate their hope through medical technology.  We have reached a point where once we get full control (breathing tube, central line, dialysis catheter) it is extraordinarily difficult for a patient to die.  

Kidney failure was a fatal diagnosis until dialysis was invented as a method to keep people alive until their kidneys recovered.  Then the technology improved enough to allow people to continue living as long as they stayed on dialysis.  Currently Medicare reimburses ~$25,000 per year per dialysis patient for the therapy alone not to mention the patient's medications or recurrent hospitalizations for clinical decompensation.  

[forgetful]

Speaking of arms race...I got a tour of the new Oregon Ducks arena today.  Incredible facility

I've only seen pictures, but absolutely ridiculous.  I wish I could live there.  Heck, I wish I could just vacation there for a weekend.

[ChicosBailBonds]

I've only seen pictures, but absolutely ridiculous.  I wish I could live there.  Heck, I wish I could just vacation there for a weekend.

There is this glass building across the street that is really strange design.  I asked what it was and they indicated it is 100% for student athletes academic affairs - studying etc.

Crazy

[GooooMarquette]

Patients and their families haven't recently changed their preferences on avoiding death but we have massively extended our ability to facilitate their hope through medical technology.  We have reached a point where once we get full control (breathing tube, central line, dialysis catheter) it is extraordinarily difficult for a patient to die.  
 

Agreed.  And the reason it's so difficult to just let patients die?  Patients/families often demand that providers do "everything they can" to prolong life.  I work with doctors everyday who tell me that extending the care is futile - that they believe it is in the patient's best interest to let him or her die with dignity - but they feel pressured to follow the wishes of families.

Why do the families demand "everything?" Because they don't (directly) pay the bill.  "Keep grandma comatose and on life support for another week?  Why not?  It doesn't cost us anything."

[GooooMarquette]

Except these occurred at major research University hospitals/clinics.  The McAllen model is becoming the norm.  There are very few alternatives in major metro areas in many parts of the country. 

Right.  The McAllen model is becoming the norm...because of the messed up insurance system I mentioned in my earlier post.  And by the way, being a major research university doesn't necessarily make it a high value provider.

[GooooMarquette]

I'm done with healthcare debates.

Back to school facilities...my daughter started at Mizzou last fall.  The rec center is crazy - swimming pools, martial arts studios, cardio, weights -- all the usual stuff.  But you can also "float down a lazy river in the Tiger grotto."  I didn't make that up.

[Silkk the Shaka]

Unlikely, because the powers that be will also scream about teacher to student ratios and all that BS.  So more students, more support hires and more professors to keep their magical ratio in tact.

Teacher to student ratio is "BS"? It's a distinguishing factor that makes the experience unique, and a reason many (including myself) chose MU over a cheaper public option. I still have valuable relationships with professors that I maintain to this day because of it. So I hope someone does the screaming in favor of maintaining the ratios.

[ChicosBailBonds]

I'm done with healthcare debates.

Back to school facilities...my daughter started at Mizzou last fall.  The rec center is crazy - swimming pools, martial arts studios, cardio, weights -- all the usual stuff.  But you can also "float down a lazy river in the Tiger grotto."  I didn't make that up.

Oregon's student rec center, didn't appear to be anything to write home about.  Having said that, I was only on that side of campus yesterday for a few minutes so I may have missed another facility.

[ChicosBailBonds]

Food and clothes are needs too, but haven't increased at nearly the rate of education and healthcare.  Want to guess why?  Because consumers pay directly for them.

supply has something to do with it as well, as does the cost to produce clothes and food....totally different animals.

[GooooMarquette]

Teacher to student ratio is "BS"? It's a distinguishing factor that makes the experience unique, and a reason many (including myself) chose MU over a cheaper public option. I still have valuable relationships with professors that I maintain to this day because of it. So I hope someone does the screaming in favor of maintaining the ratios.

I agree that teacher/student ratio is important.

However, you have to be careful when interpreting the general numbers you see from schools.  Both of my daughters go to large public universities, so if you look at the published ratios, they're considerably worse (higher) than MU's.  But they chose specific majors at those schools that have more favorable ratios, and thus far, neither has had more than one large "lecture hall" type class.  Instead, most of their classes have a professor (very rarely a TA) and about 10-20 students.  They know students in other majors that regularly have 100+ students (kind of like when I majored in Biology at MU).  

As always, YMMV.

[Warrior Code]

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[JakeBarnes]

If I win this Powerball tonight, how much would I have to donate to get the facility named the "Warrior Code Ain'a Hey Sports Palace"?

5, 10 million?

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[rocky_warrior]

If I win this Powerball tonight, how much would I have to donate to get the facility named the "Warrior Code Ain'a Hey Sports Palace"?

5, 10 million?

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[JakeBarnes]

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