OT: Ray, how's your Bitcoin investment going?

[jblande]

Originally Posted by witcombusa

Nothing beats the intolerance of people who can only stand to hear their own views echoed back at them...

93ledgendti, your opinion is as good as any other forum members

for the record, it's because i believe the 93legendti is hostile to reasoned disagreement that i said what i did.

[2LeftCleats]

Another long-time practicing primary care doc here. Thread has drifted way off bitcoin, but interesting.

There is no perfect healthcare system. The best we can do is find the balance between the best care and a sustainable system. What we currently have really accomplishes neither very well. IMO some form of universal insurance system untethered to employment would be the best compromise. Expanding Medicare to all is one approach. It has it's quirks and detractors, but overall works reasonably well at low overhead, and patients are mostly happy with it. The Anthems and Uniteds are profit-driven and aggressively limit care and reduce reimbursement. Not all of that is inappropriate, but with unconscionable CEO salaries and bonuses tied to that profit, it's hard to see patient well-being at the center of the these efforts. It's amazing how much time and money is wasted trying to get prior authorizations.

Another approach championed several years ago in their book "Critical Condition", Barlett and Steele suggest a Fed-style (aah-there's the bitcoin tie-in) approach with a centralized coordination of healthcare and healthcare research including oversight of drug and device development. There is currently insufficient evaluation of new stuff. Too often, the latest scan seems like it should work, is profitable, and quickly becomes the standard of care. Later, after careful review, we find that it has only driven up costs with little benefit.

Obamacare is the bastard stepchild of an ineffectual president and a hostile House. It doesn't really go far enough to do a lot of good, the implementation has been unbelievably inept, and may be smothered in its crib. I wish a public option would have been allowed at least as a demonstration project.

We as a nation must realize that there is probably enough money currently in the system to give everyone what he needs, but not necessarily everything he thinks he needs. We don't need antibiotics for colds, MRIs for all back pain, futile care at the end of life, etc. We do need better immunization coverage, infant care, etc. As mentioned previously, it wouldn't hurt if as much effort and money went into promoting healthful living as it now does for fast food and video games. Healthcare starts at home.

[verticaldoug]

Originally Posted by 2LeftCleats

Another long-time practicing primary care doc here. Thread has drifted way off bitcoin, but interesting.

There is no perfect healthcare system. The best we can do is find the balance between the best care and a sustainable system. What we currently have really accomplishes neither very well. IMO some form of universal insurance system untethered to employment would be the best compromise. Expanding Medicare to all is one approach. It has it's quirks and detractors, but overall works reasonably well at low overhead, and patients are mostly happy with it. The Anthems and Uniteds are profit-driven and aggressively limit care and reduce reimbursement. Not all of that is inappropriate, but with unconscionable CEO salaries and bonuses tied to that profit, it's hard to see patient well-being at the center of the these efforts. It's amazing how much time and money is wasted trying to get prior authorizations.

Another approach championed several years ago in their book "Critical Condition", Barlett and Steele suggest a Fed-style (aah-there's the bitcoin tie-in) approach with a centralized coordination of healthcare and healthcare research including oversight of drug and device development. There is currently insufficient evaluation of new stuff. Too often, the latest scan seems like it should work, is profitable, and quickly becomes the standard of care. Later, after careful review, we find that it has only driven up costs with little benefit.

Obamacare is the bastard stepchild of an ineffectual president and a hostile House. It doesn't really go far enough to do a lot of good, the implementation has been unbelievably inept, and may be smothered in its crib. I wish a public option would have been allowed at least as a demonstration project.

We as a nation must realize that there is probably enough money currently in the system to give everyone what he needs, but not necessarily everything he thinks he needs. We don't need antibiotics for colds, MRIs for all back pain, futile care at the end of life, etc. We do need better immunization coverage, infant care, etc. As mentioned previously, it wouldn't hurt if as much effort and money went into promoting healthful living as it now does for fast food and video games. Healthcare starts at home.

Infant mortality rates can be a pretty good measure about the state of total healthcare system. Compared to other industrialized nations, the U.S. is pretty poor here. United States 5.9 Canada 4.78 UK 4.5 Czech 3.7 Germany 3.48 Japan 2.17 just to name a few.

Japan accomplishes this with a single payer NHS. Contributions are progressive and based on income. For regular salary, the max is around $6000. Bonus are considered separately and these can taxed to another $17,000.

Japan spends approximately 7% of GDP and accomplishes a lot. Cost containment is a big component of the system.

[PQJ]

Great post 2LeftCleats. That's the dialogue we ought to be having but it occurs oh so infrequently.



MODS: PLEASE ADD 'LIKE' BUTTON OR SOMETHING LIKE IT. THANKS.

[malcolm]

Originally Posted by verticaldoug

Infant mortality rates can be a pretty good measure about the state of total healthcare system. Compared to other industrialized nations, the U.S. is pretty poor here. United States 5.9 Canada 4.78 UK 4.5 Czech 3.7 Germany 3.48 Japan 2.17 just to name a few.

Japan accomplishes this with a single payer NHS. Contributions are progressive and based on income. For regular salary, the max is around $6000. Bonus are considered separately and these can taxed to another $17,000.

Japan spends approximately 7% of GDP and accomplishes a lot. Cost containment is a big component of the system.

Good article about the cause of the us high infant mortality rate. Basically it's related to the high rate of premature birth here. The don't really know why that exists or at least can't fully explain it. It probably multifactorial related to life style, comorbidities of the mother and many other factors. I don't know that you can reliably use it as an indicator of the overall state of healthcare. It's like looking at the steering wheel for the overall condition of the car.

http://stanmed.stanford.edu/2013fall/article2.html

[cfox]

Originally Posted by fuzzalow

To make an omelette you gonna have to break a few eggs.

All kidding aside, the particular circumstances have to be looked at to determine if there really was damage done or if people are grousing over having to make a change and what the effect of the change was.

For example, some of the well publicized "losers" in the Affordable Care Act (ACA) were confined to an estimated 3% who had a coverage change because their prior plan did not meet the minimum standard for coverage as far as a cap on out of pocket costs per year. Their old policies were cheaper because the coverage was lower quality than the new minimum required by ACA.

Broken egg here. I am a loser in the wake of ACA, but other than my griping on Paceline, my plight has not gotten any publicity. Like I've written before, me and my business partner both saw our premiums rise by 50% and our out of pocket max go from $3,000 to $12,000, all for less coverage than our prior outlawed plans*. While I certainly don't like the changes, I can "afford" them which is precisely why I am not considered a "loser" in the process. I'm just someone expected (forced) to sacrifice more for the greater good, though I'm not certain many more people are going to wind up with coverage.

Seriously, it's not just some story on Fox News; ACA has caused a lot of angst.

*It turns out my prior plan was ACA compliant, but my insurer decided to nuke it anyway

[pbarry]

Good stuff Malcolm! Being in the trenches, your opinion holds more sway, for me at least.

Recently had my first WC claim in 20+ years. I was amazed by the attention I was given and the accelerated timeline from intake to the MRI appointment. Figure it's got to do with guaranteed payment for WC cases(?). Not done yet, but I have been very impressed with the level of care I've received thus far.

Keep on, y'all are heroes, and the political dialog rarely addresses your arduous training and work schedules.

Be Well

Originally Posted by malcolm

Hey I'll leave some perspective on health care from someone who's practiced emergency medicine for 20 years.

First off it's difficult to compare systems from other countries and say one is better. Better has many different facets. Acute care medicine in the US is the best available, in my opinion. By acute care I mean if you have an injury or illness that is life threatening and demands immediate attention. We also do very well with catastrophic illness assuming you are insured and have had a modicum of prior treatment and were dx early. Few countries do as well as we do in these instances. A frequently cited statistic is infant mortality where we lag behind but if you look at the way the data is collected and what's excluded it can yield a different result.

Where we do poorly is preventative medicine. Medical practice in the US in my opinion for the most part quit being about health maintenance and disease prevention years ago and became focused on controlling symptoms and parameters of disease. Essentially selling drugs. Most diabetics would respond to exercise and weight loss, but for the most part we don't address that for many reasons. Just a quick look at the meds people are on will tell you something, almost every person I see is on an SSRI, something for attention/focus, reflux and the list goes on.

I've always been quite conservative, grew up in a single parent family, mom with two jobs. Paid my way through school. Had very little belief in free lunch. As I've gotten older I'm becoming convinced medicine will never be effective in a capitalistic system, nothing against capitalism, just don't think it works well in medicine especially independent primary care if for no other reason than it hinders the physician from telling the patient the whole truth because you have to preserve them as a customer. I've transitioned from the ER to an urgent care setting and I've seen the difference in me. In the ER, at least before the advent of patient satisfaction surveys and satisfaction tied to your income I did what I thought was right and necessary and really didn't give much consideration to what you wanted unless I thought you needed it. I now give way more steroid shots and antibiotics to people who really don't need them but are convinced they do. Many studies are done more based on patient desire than need. I think it also lends its self to loss of clinical practice of medicine. If you see a patient and treat them conservatively and they don't get better very likely they'll go somewhere else and if tests done then reveal they had X then they assume you were incompetent because you were conservative on the first visit. That in turn creates many unnecessary work ups, driving up costs.

We also as a group tend to have unrealistic expectations of medicine and insurance. If you talk to average joes they can't understand why everyone can't have this totally unrestricted insurance where they can go to the doctor anytime they want for any reason and not cost a dime. We want mack daddy coverage for everyone but nobody wants to pay. One thing some people don't realize is how much some of their fellow man go to the doctor. It's not unusual to look at the roles of a family practice clinic or walk in clinic and see people that go to the doctor for colds 6-8 times a year with only a 10-30 cost to themselves. This again drives up costs but the consumer has no real skin in the game. I don't think you have this kind of usage in most socialized systems.

I'm not sure what the answer is, but I do think it's broken. Sorry if this is rambling it was just off the top of my head. I've been amazed at how many really smart people have no idea about their own healthcare.

One last thought. I just read an article in the New York Times that bemoaned the income of physicians and gave numbers suggesting these increases in physician income. I'm not going to whine much because medicine afforded me a good living, but trust me I worked hard for, long hours, many holidays and weekends, missed recitals, birthdays, Christmases, etc. I don't personally know one physician that makes any more money now than they did 10 years ago unless their status has changed (become a partner). I spent my entire ED career with the same group in the same ER and my income change one time, when I became partner. I made the exact same amount of money the day I quit as the day I became partner. My wife is a radiologist and they are making about the same amount they did 10 years ago, some private practice guys actually make less due to restrictions on outpatient imaging centers.

Interesting discussion and I hope you younger guys live to see medicine be what it should be. I'm not sure government control is the answer and there will be painful fits and starts but something has to change.

One other thing I'll add is look at the cost of taking care of the elderly. It consumes most of our health care dollar. I'm not saying don't take care of the elderly but you need to do it with clinical decision making. Many of the preventative things we do don't necessarily add to life. Chasing PSAs on guys that are 80 and many other examples. Our end of life care is appalling we let our elderly die a cell at a time long after they've had a lucid thought and trust me that's way expensive. I suspect if you look at socialized systems these sort of things are not done.

[fuzzalow]

Originally Posted by djg

Ok, you were kind enough in your response that I'll say something -- some very general things, anyway. First, yeah it's a swamp. Second, WRT pharma profits, it's true that they can be extremely high and, in some specialty drug cases, troubling indeed. But let's notice, first, the increasing (already majority) share of Rx sales moving to generics (the recent "patent cliff" is really a drop in a long-running trend). Some generics are still relatively pricey, but many are dirt cheap, average prices are even lower than in many countries that exert buying power -- say, Canada, at least via the provinces (well, we do it too, just not across the whole market). WRT branded drugs, read the economic literature on pharm. development and, in broad strokes, this is the ideal case -- truly, one of the only strong cases -- for strong, long-term patent protection. New drugs have a long and costly development pathway. For a NME, we're talking quite a few years and a billion dollars or more of development costs (from the lab through the Phase III clinical trials) where those large sunk costs are at risk, both in the sense that the trials may not pan out, post-approval issues might not be apparent, and in the sense that, for many products knowing the range of products that might compete more-or-less well as substitutes in the market can be pretty tricky over a big window.

Yes, businesses game the system, the various Hatch-Waxman provisions, etc., etc., and the details can get ugly in any given case. Without trying to argue that the present system is optimal -- not even as a joke on a board where most folks don't know my name -- I will suggest, first, that trying to design an optimal IP/competition balance is an intractable problem, second, that the promise of huge post-marketing profits is a key driver (necessary, I'd say) to new product development (independent of the handfuls of cool things we might get from this or that top-down long-term government project) and, third, that price discrimination can be rational for both sellers and buyers. What to do as a foreign policy matter about nations that free-ride on our expenditures is another question, and perhaps even thornier, but it doesn't alter the basic problem: how would you know, as a policy matter, what the next blockbuster drug should cost in its first year post-approval? Its third?

On the International thing, yeah, we pay tons for all sorts of things and some of those tons give very poor value for money. But most international comparisons are -- or really ought to be -- highly contentious. We've got some serious background health issues that contribute to relatively high chronic care and neonatal costs. We spend huge amounts of money on high-cost intervention late in life -- things rationed or accounted for very differently (perhaps very reasonably) in many other systems. Lop off trauma -- car accidents right up there, but also gun violence, etc. -- and you save a ton. The fact is, most people do fine with low-cost intervention most of their lives. Most Americans too. Nudge a few environmental factors and that's even more true. What should we spend on the rest of us, individually or collectively, and how should we spend it? I dunno. That's not to suggest that we have the best or third-best health care system, or even that the term "system" applies appropriately to health care, just to nod to some of the many wrinkles in the problem of international comparisons and the far more complex problem how you would "engineer" a tractable alternative, here, if you were to take a shot.

I'm not sure that bit coins or foundations of shiny rocks have anything much to do with this, but the thread had wandered, as threads do, and this seems responsive to something.

Not sure what I'm doing here -- a good follow-up question or rejoinder (and you or anybody else might have many) should ask for a 10 page paper or a stack of them, but there it is.

Thanks for the response. Some of what you posted here is over my head as I have only a rudimentary understanding of the process in FDA approval for New Molecular Entities (NME). It seems that the approval process and clinical trials imposes a tremendous time-sink to the ability for the pharmaceutical innovator to maximize its earned market monopoly position as the inventor of the NME. And we all know that time is money.

And the provisions of Hatch-Waxman do seem to shortcut and advantage generic pharmaceuticals to eat into the monopoly position from both the perspectives of time to market and piggy-backing (copying?) the conceptual breakthrough underpinning the innovation implicit to the NME. The molecular design is not per se where the genius lies but rather in the how's & whys of the targeted therapeutic interactions in achieving a desired result.

It might have been fashionable and easy to villainize Big-Pharma as one of the evils in modern life (thanks Hollywood) much less modern health care but there is always something lost in making the stereotype and missing the biggest point of all:

For better or worse, these pharmaceutical companies innovated, made a new solution that did not exist before and should be allowed to profit in a ethical fashion to the maximum that their patent-protected monopoly position allows.

If there is an inadequate time frame to have patent protections in force and effect, then perhaps that needs to be looked at and amended. In fairness, I would find it hard for the average person to be receptive as to the equity in extending patent protection for longer than 30 years from the current 20/+5 years. I think the idea won't fly because the average person sees a 30-year home mortgage as a very significant time frame and giving a patent protection beyond even that of a mortgage looks for all intents as patent protection in perpetuity.

Yes, I can be viewed as one of the culprits that drifted this bitcoin thread OT, sorry not done on purpose.

I do not work in your field or do I claim expertise in healthcare. I may be wrong about everything in this post. I am only a concerned American voter and I read. If there is indeed 10 page stacks of paper that expand on your, and your industry's, views if you can reference the literature, I'm all eyes.

[1centaur]

Workers comp is interesting to me because I have reviewed the investment case for a number of companies that specialize in "handling" WC for companies. There's an intersection of interests in that business: employers want workers back at work; the state wants reporting of both fair treatment and outcomes; insurers want WC claims to be short and finite; most workers want their conditions healed though employers at least think that some will milk the opportunity. In a more sinister light, WC administrators could be seen as limiting choices, HMO style, so the claim costs less. More positively, they can be seen as focusing the treatment so time and tests are not wasted on the wrong stuff by opportunistic providers. They provide expertise in getting an expedited cure where the patient has no such expertise. I always have some suspicion that it's easier to limit care than to maximize outcomes.

So when pbarry says he is surprised at the accelerated time line, I suspect that's because a company is truly focused on his case in a well worn groove of actions. Which begs the question: could we have single administrator, rather than single payer, who worked that groove for everything, not just worker's comp? One set of billing codes; outcomes based. Payers pick the menu of available treatments (maybe with some minimum viewed as societally good), billers compete to look good in the outcomes based rankings with costs made public on a standardized schedule.

But I suppose if it can be described in a couple of sentences on a cycling forum it's woefully inadequate.

[Climb01742]

Originally Posted by malcolm

Hey I'll leave some perspective on health care from someone who's practiced emergency medicine for 20 years.

First off it's difficult to compare systems from other countries and say one is better. Better has many different facets. Acute care medicine in the US is the best available, in my opinion. By acute care I mean if you have an injury or illness that is life threatening and demands immediate attention. We also do very well with catastrophic illness assuming you are insured and have had a modicum of prior treatment and were dx early. Few countries do as well as we do in these instances. A frequently cited statistic is infant mortality where we lag behind but if you look at the way the data is collected and what's excluded it can yield a different result.

Where we do poorly is preventative medicine. Medical practice in the US in my opinion for the most part quit being about health maintenance and disease prevention years ago and became focused on controlling symptoms and parameters of disease. Essentially selling drugs. Most diabetics would respond to exercise and weight loss, but for the most part we don't address that for many reasons. Just a quick look at the meds people are on will tell you something, almost every person I see is on an SSRI, something for attention/focus, reflux and the list goes on.

I've always been quite conservative, grew up in a single parent family, mom with two jobs. Paid my way through school. Had very little belief in free lunch. As I've gotten older I'm becoming convinced medicine will never be effective in a capitalistic system, nothing against capitalism, just don't think it works well in medicine especially independent primary care if for no other reason than it hinders the physician from telling the patient the whole truth because you have to preserve them as a customer. I've transitioned from the ER to an urgent care setting and I've seen the difference in me. In the ER, at least before the advent of patient satisfaction surveys and satisfaction tied to your income I did what I thought was right and necessary and really didn't give much consideration to what you wanted unless I thought you needed it. I now give way more steroid shots and antibiotics to people who really don't need them but are convinced they do. Many studies are done more based on patient desire than need. I think it also lends its self to loss of clinical practice of medicine. If you see a patient and treat them conservatively and they don't get better very likely they'll go somewhere else and if tests done then reveal they had X then they assume you were incompetent because you were conservative on the first visit. That in turn creates many unnecessary work ups, driving up costs.

We also as a group tend to have unrealistic expectations of medicine and insurance. If you talk to average joes they can't understand why everyone can't have this totally unrestricted insurance where they can go to the doctor anytime they want for any reason and not cost a dime. We want mack daddy coverage for everyone but nobody wants to pay. One thing some people don't realize is how much some of their fellow man go to the doctor. It's not unusual to look at the roles of a family practice clinic or walk in clinic and see people that go to the doctor for colds 6-8 times a year with only a 10-30 cost to themselves. This again drives up costs but the consumer has no real skin in the game. I don't think you have this kind of usage in most socialized systems.

I'm not sure what the answer is, but I do think it's broken. Sorry if this is rambling it was just off the top of my head. I've been amazed at how many really smart people have no idea about their own healthcare.

One last thought. I just read an article in the New York Times that bemoaned the income of physicians and gave numbers suggesting these increases in physician income. I'm not going to whine much because medicine afforded me a good living, but trust me I worked hard for, long hours, many holidays and weekends, missed recitals, birthdays, Christmases, etc. I don't personally know one physician that makes any more money now than they did 10 years ago unless their status has changed (become a partner). I spent my entire ED career with the same group in the same ER and my income change one time, when I became partner. I made the exact same amount of money the day I quit as the day I became partner. My wife is a radiologist and they are making about the same amount they did 10 years ago, some private practice guys actually make less due to restrictions on outpatient imaging centers.

Interesting discussion and I hope you younger guys live to see medicine be what it should be. I'm not sure government control is the answer and there will be painful fits and starts but something has to change.

One other thing I'll add is look at the cost of taking care of the elderly. It consumes most of our health care dollar. I'm not saying don't take care of the elderly but you need to do it with clinical decision making. Many of the preventative things we do don't necessarily add to life. Chasing PSAs on guys that are 80 and many other examples. Our end of life care is appalling we let our elderly die a cell at a time long after they've had a lucid thought and trust me that's way expensive. I suspect if you look at socialized systems these sort of things are not done.

Malcolm, if there were ever a study group put together to 'solve' our healthcare system, I hope you, or doctors like you, are sitting at the table. Thanks for taking the time to share a from the trenches POV.

[fuzzalow]

Originally Posted by cfox

Broken egg here. I am a loser in the wake of ACA, but other than my griping on Paceline, my plight has not gotten any publicity. Like I've written before, me and my business partner both saw our premiums rise by 50% and our out of pocket max go from $3,000 to $12,000, all for less coverage than our prior outlawed plans*. While I certainly don't like the changes, I can "afford" them which is precisely why I am not considered a "loser" in the process. I'm just someone expected (forced) to sacrifice more for the greater good, though I'm not certain many more people are going to wind up with coverage.

Seriously, it's not just some story on Fox News; ACA has caused a lot of angst.

*It turns out my prior plan was ACA compliant, but my insurer decided to nuke it anyway

It is too bad that this has happened with your plan. And I am not defending what they did or do but I would like to present a slightly different perspective on this.

Some precepts:

• Insurance works by the pooling of persons so that the risks may be shared across a large superset of potential occurrences
• The insurance companies are not in the business of paying out money (claims)
• Insurance is all about the actuarial numbers
• There is no such thing as a free lunch

In theory, all insurance, fairly allocated (to all policy holders) and with equal financial exposure as to terms, payouts and conditions (for the underwriter) will cost the same to everyone.

If you got a better deal, something had to give to get you that better deal. For example, if your insurer wrote policies the discriminated for prior conditions as a way to increase the quality of the pool that you were in, they could offer you a better rate on your coverage. That's before even getting to the fine print in the policy as far as deductibles, co-pay amounts and coverage limits and caps on the basis of treatment types, illness classifications, etc, etc, etc.

In financial terms, which seems largely appropriate to me as insurance is a financial product, there are higher and lower quality tranches established targeting expected rates of return for any given block of underwriting that must be done. If you are a young, healthy male - they want you. If you are a middle-aged, healthy male that has a sparse claim history - then they really want you.

A comment was made earlier, that no one reads the fine print of their health policy. I have never read the fine print of my health care plan. It is the fine print that creates opacity and the advantage the insurers hold over the policyholders.

[djg]

Originally Posted by fuzzalow

Thanks for the response. Some of what you posted here is over my head as I have only a rudimentary understanding of the process in FDA approval for New Molecular Entities (NME). It seems that the approval process and clinical trials imposes a tremendous time-sink to the ability for the pharmaceutical innovator to maximize its earned market monopoly position as the inventor of the NME. And we all know that time is money.

And the provisions of Hatch-Waxman do seem to shortcut and advantage generic pharmaceuticals to eat into the monopoly position from both the perspectives of time to market and piggy-backing (copying?) the conceptual breakthrough underpinning the innovation implicit to the NME. The molecular design is not per se where the genius lies but rather in the how's & whys of the targeted therapeutic interactions in achieving a desired result.

It might have been fashionable and easy to villainize Big-Pharma as one of the evils in modern life (thanks Hollywood) much less modern health care but there is always something lost in making the stereotype and missing the biggest point of all:

For better or worse, these pharmaceutical companies innovated, made a new solution that did not exist before and should be allowed to profit in a ethical fashion to the maximum that their patent-protected monopoly position allows.

If there is an inadequate time frame to have patent protections in force and effect, then perhaps that needs to be looked at and amended. In fairness, I would find it hard for the average person to be receptive as to the equity in extending patent protection for longer than 30 years from the current 20/+5 years. I think the idea won't fly because the average person sees a 30-year home mortgage as a very significant time frame and giving a patent protection beyond even that of a mortgage looks for all intents as patent protection in perpetuity.

Yes, I can be viewed as one of the culprits that drifted this bitcoin thread OT, sorry not done on purpose.

I do not work in your field or do I claim expertise in healthcare. I may be wrong about everything in this post. I am only a concerned American voter and I read. If there is indeed 10 page stacks of paper that expand on your, and your industry's, views if you can reference the literature, I'm all eyes.

Any thread might wander a bit and you'll get no complaint from me if you helped drift this one off the topic of bit coins. FWIW, I don't think there's anything crazy about your concerns. Frankly, I don't recall them going back through the entire thread, but looking at this post I have to say that we'd do very well indeed if the typical voter could think about some of these issues at the level you've crammed into a single, brief chat-board response. At the same time, (a) there's no good reason anybody should seek to replicate the particular basket of human capital goods I bring to the health policy table and (b) for most stuff, I have no easy answers.

I don't want to type here in any professional capacity, and I sure-as-···· don't want to pretend to represent my employer, or seem to. I'm not, by the way, employed in the pharmaceuticals industry -- not by big pharma or small, not by branded/innovator firms or generics, not by a trade association or lobbying entity affiliated with any or all of 'em. I picked it as one example of how complicated or messy it gets. Easy to bemoan 300 or 1200 percent markups -- and we might cry if we start looking at particular people who get left out in particular cases -- but as you yourself see in a flash, if pills sell at perfectly competitive prices (the marginal cost of producing the next pill) or anything like them, then there's no rational business path to developing the next blockbuster drug to begin with. Sure the regulatory costs are high, and there too I won't pretend to argue that we've nailed it (optimizing across all our properly weighted policy priorities? do we do that kinda thing?), but there are very few folks indeed who decry the basic idea of substantial pre-clinical and clinical testing requirements for the next blood pressure pill or cancer treatment.

Moving to physician-centered issues or hospital-centered issues doesn't make it easy either.

If you have a question about this or that, you can send it to me off-line. I don't promise anything but to read it. If I can think of what seems to me a decent source, I'll point you to it. You yourself can be the judge whether or to what extent it's useful to you.

[PQJ]

Originally Posted by fuzzalow

It is too bad that this has happened with your plan. And I am not defending what they did or do but I would like to present a slightly different perspective on this.

Some precepts:

• Insurance works by the pooling of persons so that the risks may be shared across a large superset of potential occurrences
• The insurance companies are not in the business of paying out money (claims)
• Insurance is all about the actuarial numbers
• There is no such thing as a free lunch

In theory, all insurance, fairly allocated (to all policy holders) and with equal financial exposure as to terms, payouts and conditions (for the underwriter) will cost the same to everyone.

If you got a better deal, something had to give to get you that better deal. For example, if your insurer wrote policies the discriminated for prior conditions as a way to increase the quality of the pool that you were in, they could offer you a better rate on your coverage. That's before even getting to the fine print in the policy as far as deductibles, co-pay amounts and coverage limits and caps on the basis of treatment types, illness classifications, etc, etc, etc.

In financial terms, which seems largely appropriate to me as insurance is a financial product, there are higher and lower quality tranches established targeting expected rates of return for any given block of underwriting that must be done. If you are a young, healthy male - they want you. If you are a middle-aged, healthy male that has a sparse claim history - then they really want you.

A comment was made earlier, that no one reads the fine print of their health policy. I have never read the fine print of my health care plan. It is the fine print that creates opacity and the advantage the insurers hold over the policyholders.

The problem is, it's all so fuzzy. No transparency at all. No sense or rationality at all. cfox's story sucks. No doubt there are many more like it. But there are many completely opposite stories as well. Like mine. I struck out on my own last July. Left an employer and group coverage so that I could be a "small businessman" and "job creator (in waiting")." Pregnant wife meant I couldn't get an individual policy until the ACA kicked in. So I was stuck getting screwed by COBRA, which is fine I guess since I can afford it.

Fast forward to 1/1/14. I'm now on a plan that (i) costs less in premiums than my old employer-sponsored plan, (ii) has lower deductibles and copays, and (iii) has much richer coverage. Why? How does this make sense? I have no frikkin clue.

I do know that:
1. drugs that used to cost me $120 and $190, respectively, per prescription, have now dropped to $10 (and some change) and $15 (and some change), respectively. The $190 drug is a tiny bottle of eyedrops for my daughter who has sever allergies.

None of this makes any sense to me. No statement I ever receive from any medical provider ever makes sense to me. No statement I ever receive from my dentist ever makes sense to me. The people I speak to, in billing at the provider's office, in administration at the insurance company, never, ever, ever make sense to me.

I know that the delivery of healthcare services is incredibly complex. So complex that I can't make sense of it in an intelligent way. But I'm pretty sure that I'm spot on with this: all the crap we deal with, all the obfuscation, all the lack of transparency, all the insane costs, the inhumanity of it all, has at its root the following: greed/$$/capitalism/the free market.

And for the doctors among us, I want to be clear that they're not the problem. But we live in a screwed up world and the almighty greenback is the root of many of our problems.

I represented PE funds while practicing law in New York during the 'golden age.' One of the senior guys I worked for - let's call him J - , was worth around $100 million in 2003 at age 39; today his net worth is north of $2 billion. One of the grunts I worked with (28-year bulldog at the time, super smart, very hard worker), sat on a board of a portfolio company his fund acquired for 1 year, and left with options valued at $2.1 million (this ignoring any base or incentive comp he received in addition) - let's call him S. Today, at age 38, he is worth around $500 million.

Don't get me wrong. S and J are both smart guys, both hard workers. But there is no way they have created the 'value' they think they have, and there is no way in hell they are worth what they are worth because of what they have done for humankind.

Sad, sad state of affairs over all.

/rant and off to yoga

[malcolm]

Some of the problem is with advances/increases in technology and complexity. I do not mean technology in form of diagnosis and treatment I mean more application. For years doctors ran medicine and had control of their profession. As medicine became more complex both in technology and more in billing and reimbursement and the business side it became more than most physicians could deal with and business men and business models moved in. The same basic rules of business used to run say Nabisco have been used with minimal modification to now run hospitals and healthcare and we are finding that it doesn't work the product is fundamentally different. I think it's evolving but hasn't yet reached a workable model.

Early in my career you did what needed to be done submitted a bill and were paid. We now have an entire industry that has been created to determine the maximum way to submit your bill and it's constantly evolving. Somewhere around 8% of our income is spent on coding, billing and reimbursement in the two clinics I'm part owner of. If I'm being honest even going back to my ER days it has a certain feel of dishonesty about. You have to do or say just the right things to maximize reimbursement, make sure all the boxes are ticked. Sorry to ramble but this topic gets me stirred up. Most providers want to provide a good product for a fair price to a satisfied patient and so often it seems the provider and patient are in an antagonistic relationship.

[cfox]

Originally Posted by fuzzalow

It is too bad that this has happened with your plan. And I am not defending what they did or do but I would like to present a slightly different perspective on this.

Some precepts:

• Insurance works by the pooling of persons so that the risks may be shared across a large superset of potential occurrences
• The insurance companies are not in the business of paying out money (claims)
• Insurance is all about the actuarial numbers
• There is no such thing as a free lunch

In theory, all insurance, fairly allocated (to all policy holders) and with equal financial exposure as to terms, payouts and conditions (for the underwriter) will cost the same to everyone.

If you got a better deal, something had to give to get you that better deal. For example, if your insurer wrote policies the discriminated for prior conditions as a way to increase the quality of the pool that you were in, they could offer you a better rate on your coverage. That's before even getting to the fine print in the policy as far as deductibles, co-pay amounts and coverage limits and caps on the basis of treatment types, illness classifications, etc, etc, etc.

In financial terms, which seems largely appropriate to me as insurance is a financial product, there are higher and lower quality tranches established targeting expected rates of return for any given block of underwriting that must be done. If you are a young, healthy male - they want you. If you are a middle-aged, healthy male that has a sparse claim history - then they really want you.

A comment was made earlier, that no one reads the fine print of their health policy. I have never read the fine print of my health care plan. It is the fine print that creates opacity and the advantage the insurers hold over the policyholders.

The only tranche available now to health insurers is age. The theory behind ACA: trash the tranche process -> require everyone to join the risk pool -> much larger risk pool will offset the (prior uninsurable tranche) unhealthy. The theory breaks down if new, healthy membership lags and people pay the penalty rather than join the pool. The people who don't qualify for the subsidy but still buy insurance make up a large part of the difference (me). Honestly, I'd be okay with it if I were confident the % of uninsured would be reduced by a significant margin, but so far that is not the case.