Healthcare Reform Thread II

[Guynemer]

Otolaryngologists, ophthamologists, allergists, pharmacologists...

[Jon Miller]

It included some (or all?) of those but I didn't include them in my counts of doctors. That would be the fault of the person I copied my answer from (not the statistics site). Also, I don't know what some of those are (and I didn't realize that some of those were classified as doctors).

However, I did compare the two sources for a single subfield, and KH's source was 50-100% higher. So that isn't the most significant part of the descripency.

JM

[Drake Tungsten]

Diagnosticians.

[Guynemer]

Totally fictional made-up bull****.

But entertaining as hell.

(And I think he's also a board-certified nephrologist, n'est pas?)

I didn't realize that some of those were classified as doctors

What did you think they were?

[Jon Miller]

I thought pharmacy was a separate thing.

JM

[Kuciwalker]

gastroenterologists

I don't think these actually exist. I think it's a word made up by doctors to make them sound like they have all kinds of super-complex stuff to do.

[Guynemer]

Nope Kuci, they really exist, believe it or not. They make crazy amounts of money by shoving a long flexible fiberoptic camera up your pooper. They tend to be... interesting people.

I thought pharmacy was a separate thing.

JM

Ahh. Okay. Not pharmacists; pharmacologists (or toxicologists).

Sort of like psychologists are not psychiatrists.

[Drake Tungsten]

They make crazy amounts of money by shoving a long flexible fiberoptic camera up your pooper.

I wish someone had told me about this option before I abandoned pre-med.

[Guynemer]

Hindsight. She is a *****.

[KrazyHorse]

This is not the specific kind of example you're talking about, but it's part of the theme. There's a rule to keep Medicare spending growth at GDP growth. Starting in 2002, it has been too high. Every year payments to doctors are scheduled to be cut. Every year, starting in 2003, Congress passes legislation reversing it. Last year, they were to be cut by 10.6%, but instead was raised by 1.1%.

http://www.msnbc.msn.com/id/31495588...-capitol_hill/

Cutting payments to doctors is precisely what we're not talking about. That's just playing chicken with the docs to see at what point they start refusing to treat medicare patients. I'm talking about HARD decisions. Like "we aren't going to fund this modern treatment because there are only marginal improvements" type of hard. Medicare PRECISELY DOESN'T do this.

[DaShi]

Totally fictional made-up bull****.

But entertaining as hell.

(And I think he's also a board-certified nephrologist, n'est pas?)

I've heard that it's becoming too common that patients will ask to see the Chief of Diagnostic Medicine at their local hospital.

[DaShi]

Cutting payments to doctors is precisely what we're not talking about. That's just playing chicken with the docs to see at what point they start refusing to treat medicare patients. I'm talking about HARD decisions. Like "we aren't going to fund this modern treatment because there are only marginal improvements" type of hard. Medicare PRECISELY DOESN'T do this.

That's not easy to do from a policy standpoint. For one, there's a lot of conflicting research about how successful some techniques really are. this ranges from lack of resources to do studies to special interests influencing the outcomes. For doctors, they don't always rely on the scientific results, rather they feel that this fits into the "art" of medicine. However, that could just be an excuse in some cases. The main issue is that there remain too many vagaries in health research, especially with the new modern treatments.

The other issue is how close you come to actually dictating and making decisions for doctors. If we just use what is scientifically proven to work, then the treatment for everyone will be the same. Say goodbye to personalized care and hello to endless bureaucracy. This is the complaint that many doctors have with private utilization review boards that can deem necessary treatment as unnecessary in the name of profit and cost cutting. The irony is that many people who fear this in government sponsored health care seem to ignore how common it is in the private sector.

Now I'm not saying that this can't be done or won't be helpful in cutting costs. It's just that the line has to be drawn carefully. One of the great obstacles to providing value in medical care is exactly how to measure that value. Without that, it is difficult to accomplish effective reform.

[Sava]

i say, put their head in a vice

[Drake Tungsten]

The CBO quantifies the cost savings of MedPAC reform and finds them lacking...

For the second time this month, congressional budget analysts have dealt a blow to the Democrat's health reform efforts, this time by saying a plan touted by the White House as crucial to paying for the bill would actually save almost no money over 10 years.

A key House chairman and moderate House Democrats on Tuesday agreed to a White House-backed proposal that would give an outside panel the power to make cuts to government-financed health care programs. White House budget director Peter Orszag declared the plan "probably the most important piece that can be added" to the House's health care reform legislation.

But on Saturday, the Congressional Budget Office said the proposal to give an independent panel the power to keep Medicare spending in check would only save about $2 billion over 10 years- a drop in the bucket compared to the bill's $1 trillion price tag.

"In CBO's judgment, the probability is high that no savings would be realized ... but there is also a chance that substantial savings might be realized. Looking beyond the 10-year budget window, CBO expects that this proposal would generate larger but still modest savings on the same probabilistic basis," CBO Director Douglas Elmendorf wrote in a letter to House Majority Leader Steny Hoyer on Saturday.

http://www.politico.com/news/stories/0709/25415.html#ixzz0MJHF9JSd

I guess Ramo needs to find a new variety of pixie wings to put his faith in.

[Ramo]

Cutting payments to doctors is precisely what we're not talking about. That's just playing chicken with the docs to see at what point they start refusing to treat medicare patients. I'm talking about HARD decisions. Like "we aren't going to fund this modern treatment because there are only marginal improvements" type of hard. Medicare PRECISELY DOESN'T do this.

Well, cutting doctors fees by definition has a much larger effect than cutting a specific kind of treatment since it presumably would effect much more people. So I don't know what you mean about "hard decisions." That aside, I was misinformed about the decision making process. MedPac does exactly make these sorts of recommendations (for example, imaging reimbursement), but they are completely advisory. The organization actually in charge, the CMS, is not independent of the President (and is under HHS).

And naturally, they've been reticent about proposing significant cuts. Looking through the past few years, I can only find trivial changes that Congress reversed (the most significant I could find is about capping oxygen tank reimbursement). I did see what appears to be a nontrivial change that new Admin's CMS implemented, denial of coverage for a virtual colonoscopy. Obviously, Congress hasn't had time to reverse the decision (and is currently under some political constraints not to increase health care costs), so let's see what happens.

The question is whether the Rockefeller/Orszag proposal could give sufficient weight and independence to MedPac. I don't see a need to be skeptical. As I was saying, we largely were successful in terms of giving the Fed independence (even if there were some major mistakes in recent years).

The CBO just scored Orszag's proposal, and saw no savings over the ten year period. This is largely because the entity doesn't come online until 2015, the budget window ends in 2019, and we're seeing Congress cut deals with the various stakeholders to wring more money out of Medicare (cost savings add up to ~a few hundred billion $/ten years). Elmendorf, however, points out that past the budget window, we could expect a reduction several percent out of Medicare, or tens of billions of dollars/year if the proposal is appropriately strong. He specifically singles out a fallback mechanism, where there's an across the board reduction if the cost control guidelines are not met. The caveat here is that cost savings past the ten year budget window are extremely speculative (we have no idea what kinds of medical technology there will be in 20 years, much less what ought to be cut), and CBO accounting is notoriously conservative. So I suspect that's closer to a lower bound than an expected value.