Healthcare Reform Thread II

[Jon Miller]

Why would doctors charge you more for other peoples failure at becoming a doctor?

I know that doctors get paid decently, but most doctors just live middle class, so the huge sacrifices tha tpeople go through with a chance at becoming a doctor aren't really rational (I think). But there is no reason for doctors to include those others in their salary compensation.

If they did, then they would be payed more than they needed just to offset it (and they aren't, I maintain, due to the aforementioned middleclass life of doctors).

JM

[KrazyHorse]

a) 300k is a ridiculous underestimate. There are approximately 950k actively practicing physicians in the US

b) You can't simply divide by 20 years of active career. Or have you forgotten a little thing called "interest"?

c) You're still leaving out those who attempted to take part and failed. Their costs are OBVIOUSLY included in the costs of care.

d) Doctors pay taxes

a triples your estimate
b doubles it
c does something...not too sure what
d doubles it

so we've got a factor of at least 12 from your estimate = 360$ per year per capita

That is 1/5 of the difference in per-capita spending between the US and Canada

EDIT: dropped a factor of 2. And remember, that doesn't even take c into effect...

[Jon Miller]

In a recent year (2002), doctors spent 6kkk on medical insurance.

That is also only 20$ per person in the US. And less important than education.

JM

[KrazyHorse]

Why would doctors charge you more for other peoples failure at becoming a doctor?

Because IF THEY DIDN'T THEN NOBODY WOULD BECOME A DOCTOR

[Jon Miller]

But wouldn't that put their standing of living much higher than it would otherwise be? Which is about middle class?

And you are assuming very rational people, which is a common mis-assumption fo very rational physicists/scientists/etc.

By the way, your number for doctors doesn't fit with the medical insurance numbers, because that would imply that doctors take out only 6000 per year in malpractice insurance. I am betting that your ~1kk number includes people that aren't normally included when discussing these standard doctor issues (but might be included in the total health costs, I know my numbers don't include nurses).

JM

[Ramo]

No, you said:

I realize what I said was ambiguous, but I clarified exactly what that meant in the next post to Kuci.

I have no idea why you think that Medicare will actually restrict treatments based on comparative effectiveness research. They've proven EXTRAORDINARILY unwilling to do so in the past. In order to claim cost savings from this you have to demonstrate that the research will lead to ACTION to restrict care.

You're insisting that this is somehow intrinsic to the American system. I just specified a solution, some kind of disbursement reform. I should add that this is reform that all the key players now agree to.

You have to actually explain yourself here. You can't just say "regulated marketplace" and expect anybody to understand you.

The regulations impose constrainst on coverage (no discrimination pre-existing conditions), premium cost (a limited range that premiums can vary within), and plans (no amazing or underwhelming plans). Specific disbursement rates are not a huge leap.

I have no idea what a change in "aggregate disbursements" means. A quick google search suggests that what you're referring to was an increase to the payments made to Alaskan physicians PER PROCEDURE.

I assumed it referred to a net increase that summed up to a 35% increase in disbursements, rather than a uniform increase. My mistake, but I did add that caveat about not being certain. But it does make my point stronger. A uniform 35% increase within a state increase is even more ludicrous.

That map is of disbursements PER ENROLEE.

Yes, I don't have per procedure data. I didn't realize you were looking for that specifically. The point I was making is that Congressional meddling is not allowing the government to set disbursement at rates commensurate with the health care value that people actually get. You see that in the per enrollee data because the differences here are largely in terms of procedures that add very little to the public's health.

The government ALREADY pays significantly less than private insurers do for any given procedure.

Yes, you don't think that has an effect on private sector pyaments? More agressive bargaining by the government would obviously have a larger effect on the private market.

[KrazyHorse]

But wouldn't that put their standing of living much higher than it would otherwise be? Which is about middle class?

WTF does this mean?

And you are assuming very rational people, which is a common mis-assumption fo very rational physicists/scientists/etc.

No, what you are assuming is that for people IN AGGREGATE to display rational behaviour it means that individuals need to display rational behaiviour. And THIS is a common misunderstanding by physicists.

By the way, your number for doctors doesn't fit with the medical insurance numbers, because that would imply that doctors take out only 6000 per year in malpractice insurance. I am betting that your ~1kk number includes people that aren't normally included when discussing these standard doctor issues (but might be included in the total health costs, I know my numbers don't include nurses).

I have no idea why you're discussing nurses. I'm talking about the number of physicians (MDs) in active practice in the US. I've found numbers between 850k and 1 million.

[Jon Miller]

http://www.bls.gov/oes/2003/may/oes_29He.htm

Anesthesiologists 23,790
Family and General Practitioners 111,990
Internists, General 50,140
Obstetricians and Gynecologists 19,180
Pediatricians, General 26,910
Psychiatrists 19,530
Surgeons 49,730

Total 301,270

In 2003?

I don't think that people in aggregate display rational behavior all the time, nor even most of the time.

JM

[Ramo]

a) I'm not convinced that there is less overhead

Why?

b) I have no idea why you believe that the size of the public provider in the US would approach the size of the public providers in other developed countries, given the proposals being floated. In those countries everybody's given basically free access to the "public option". This is not what will be passed in the US.

If the public option is appropriately structured (everyone has access, it isn't a dumping ground for high risk individuals), that's effectively the steady-state that we would see.

a) The government has been exercising monopsony power on health care for old people for many decades. Where are the savings?

Why do you believe there are no savings? It would be awfully strange for there not to be savings, despite Medicare paying far less than the private sector.

b) How much of health care for under-65s is currently public in the US?

~33%, mostly split between Medicare and Medicaid.
Edit: Obviously I didn't read the question. But IIRC ~18% of the total population is in Medicaid+VA (but a lot of VA is over 65). So something like 21%.

How high do you think it will go? Will this be sufficient to exercise monopsony?

It depends. If Wyden's amendment passes, people can opt out of the employer system (along with an employer-provided subsidy) and enter the health insurance exchange, where they have an option to get the public option. In which case, the public pool could be very large. If that doesn't happen, the CBO estimated (based on the House bill) that the public option would have ~11 million people by the end of the decade.

One other issue is that the public systems could be unified. One issue is that Medicaid is operated by the states. There has been a proposal to federalize Medicaid (that would also act as a second, more efficient stimulus). I don't know where that's going.

c) I have no idea why you think it is reasonable to claim that the gov't will be able to restrict care based on cost effectiveness when it hasn't proven its ability to do so in the past.

Because there's a proposal on the table to do just that. The stumbling block was going to be liberals in the House, and they signed on last week.

[Dinner]

The GOP's health care plan is... Nothing. They don't have one. They just want to sit and do nothing while things get worse and worse, as more companies are forced in bankruptcy because of health care costs, while more people declare bankruptcy because of health care costs, etc... They won't offer any bill or any reform. Given all of their pontificating and obstructionism of the side which is actually trying to make things better (albeit not as much as I'd like) this is almost as bad as their one page numberless budget.

http://theplumline.whorunsgov.com/health-care/leader-of-gop-health-care-solutions-group-says-gop-wont-offer-health-care-bill/

[KrazyHorse]

I realize what I said was ambiguous, but I clarified exactly what that meant in the next post to Kuci.

No, what you said was simply wrong. But instead of acknowledging that and changing your argument you chose to confuse the issue.

You're insisting that this is somehow intrinsic to the American system.

That's because WE'VE SEEN EVIDENCE THAT IT IS! Adding more people to a system which doesn't control costs is NOT some sort of magic potion that will cause the system to control costs.

The regulations impose constrainst on coverage (no discrimination pre-existing conditions), premium cost (a limited range that premiums can vary within), and plans (no amazing or underwhelming plans). Specific disbursement rates are not a huge leap.

Specific disbursement rates?



So your solution is PRICE CONTROLS?

I assumed it referred to a net increase that summed up to a 35% increase in disbursements, rather than a uniform increase. My mistake, but I did add that caveat about not being certain. But it does make my point stronger. A uniform 35% increase within a state increase is even more ludicrous.

I have no idea what you mean by "within a state increase". And yes, the fact that senators can pressure a gov't agency to change what the gov't pays for services in their home state is ridiculous. What I asked you was how much this type of activity adds to total medicare costs.

Yes, I don't have per procedure data. I didn't realize you were looking for that specifically. The point I was making is that Congressional meddling is not allowing the government to set disbursement at rates commensurate with the health care value that people actually get.

In other words....that the US public health care system has proven itself unable to restrict services based on cost effectiveness? Yes, I agree with you. Which is why it might not be a good idea to throw a bunch more people into the US public health care system and assume that will somehow fix things.

Yes, you don't think that has an effect on private sector pyaments? More agressive bargaining by the government would obviously have a larger effect on the private market.

No. And if you'd think about it you'd realize why not.

[KrazyHorse]

http://www.bls.gov/oes/2003/may/oes_29He.htm

Anesthesiologists 23,790
Family and General Practitioners 111,990
Internists, General 50,140
Obstetricians and Gynecologists 19,180
Pediatricians, General 26,910
Psychiatrists 19,530
Surgeons 49,730

Total 301,270

In 2003?

JM

Would you like to continue to post the same reference over and over again, Jon?

http://www.census.gov/compendia/statab/tables/09s0157.pdf

I don't think that people in aggregate display rational behavior all the time, nor even most of the time.

That's because you're a silly person.

[Jon Miller]

When you didn't show any countering data, sure.

I am confused as to why the two statistics are so far apart.

Also, your numbers don't make sense with the medical malpractice insurance numbers I saw (the 6.3 billion spent for 2002). Do you have any numbers that work with those numbers of physicians?

JM

[Jon Miller]

As far as the rationality of people in aggregate...

What about the large percentage of the population that gets degrees in english, philosophy, etc?

What about the large percentage of the population that spends more than they make on CC, and are left with huge CC bills/etc?

What about the large percentage of the population that doesn't invest?

What about the large percentage of the population that follow astrology/etc?

What about the large percentage of investors who think that they know better than those whose job it is to find good investments?

How about those who keep voting in the same corrupt politicans every year?

Or the voters in california who vote that spending can't be increased, but that the state has to finance more items?

Or those who hold countering beleifs in science/religion/etc?

KH, your own positions have been counter to the positions of the combined population over and over again, and you are (often) right because you are rational and the aggregate is not.

JM

[Ramo]

[QUOTE=KrazyHorse;5644619]

I realize what I said was ambiguous, but I clarified exactly what that meant in the next post to Kuci.

No, what you said was simply wrong. But instead of acknowledging that and changing your argument you chose to confuse the issue.[/q]


I pointed out that universality has large up front costs, and conceded that cost savings are speculative. In the first post. I did not change my argument.

That's because WE'VE SEEN EVIDENCE THAT IT IS! Adding more people to a system which doesn't control costs is NOT some sort of magic potion that will cause the system to control costs.

I am talking about a specific mechanism to get disbursment reform.

Specific disbursement rates?



So your solution is PRICE CONTROLS?

No, I said that the hope is that the private sector would follow suit after Medicare uses results from cost effectiveness. But the framework provides an option for the government to be more aggressive if necessary. I don't think it would be.

I have no idea what you mean by "within a state increase".

Yes, I made a typo. Clever.

And yes, the fact that senators can pressure a gov't agency to change what the gov't pays for services in their home state is ridiculous. What I asked you was how much this type of activity adds to total medicare costs.

I don't know. I do know that there is similar stuff going on - members of Congress pushing for higher payments to doctors in rural areas or pushing for their favorite procedure. I don't know how to quantify this, but Elmendorf has that it is a big problem. It would be interesting to see how the CBO scores MedPac reform.

In other words....that the US public health care system has proven itself unable to restrict services based on cost effectiveness? Yes, I agree with you. Which is why it might not be a good idea to throw a bunch more people into the US public health care system and assume that will somehow fix things.

I'm not.

No. And if you'd think about it you'd realize why not.

I'm not sure what you're saying. The government compensates procedure x with, say, an order of magnitude less than the norm because of the effectiveness studies. Private insurers are not going to change their compensation scheme?