Obama making his speech to the schools...

Glenn · Post by **Glenn** » Thu Oct 01, 2009 1:49 pm

Bill Glasheen wrote: And few trust a central group to come in and force drastic change

On his show last night, Jon Stewart was making fun of the Dems failure to grasp that terminology can affect success. I forget the numbers he used, but basically polls indicate that a majority of Americans approve of a "public option" but a majority also disapprove of a "government-run option", different names for the same thing. He then showed a clip-sequence of several Dems essentially saying that it should not be called a "public option". I think as we've seen many times over, politicians can be their own worst enemies.

Jason Rees · Post by **Jason Rees** » Thu Oct 01, 2009 1:50 pm

I'm just confused as to how a government that's mangled everything it's touched in the last two decades is going to 'fix' healthcare.

Jason Rees · Post by **Jason Rees** » Thu Oct 01, 2009 1:54 pm

And on topic:

http://www.thefoxnation.com/culture/200 ... l-kid-song

Glenn · Post by **Glenn** » Thu Oct 01, 2009 6:22 pm

Jason Rees wrote: If that's gonna happen, it's gotta happen soon. I leave in January.

Well we definitely should plan something. Either in Lincoln or Omaha would work for me. I usually venture up to Omaha about once every two months anyway so going to Omaha is not an issue.

IJ · Post by IJ » Thu Oct 01, 2009 7:37 pm

The government has made mistakes in meddling with some things (my point about Iraq is that people on different sides of the debate seem to be comfortable with government screwups if they're for their personal agenda; another parallel is the fight on abortion, where people who believe one is too many and no public monies can go to it are often people who are happy to accept 50k dead Iraqis in collateral damage, exploded with funds their antiwar neighbors don't get a pass on paying into--and vice versa) but it's also made mistakes NOT meddling in things. I gave the example of the financial crisis which I've read seems to correlate pretty well with deregulation (starting with Reagan) and failure to regulate new processes.

Right now we know that if we left insurance unregulated the vast majority of Americans would be unhappy. I do believe that people should be able to buy packages free of high cost coverage--BMT, infertility care, other low yield items--provided there is an upfront understanding that the result of buying a car without side impact airbags is that sometimes you die in a t bone. This would be a step towards actual customer feeback on costs.

Despite the assumption that government run healthcare will be a mess, the rest of the West has it (in many flavors! private components too!) and gets better outcomes paying less for it.

As for who decides how to ration care, well, my vision would be that we provide basic services for people and that there are some drugs and conditions we simply won't offer. Examples include low return care at end of life, especially ICU and cancer drugs; use of anything when there is a cheaper or more effective alternative; highly expensive processes like BMT and so on. The two main ways this would happen would be:

Comparative Effectiveness Research, or CER, which was a novel component of the stimulus. American health care gets approved based on benefit vs placebo, and so we fail to find out if new drugs are superior to older cheaper ones. We desperately need more CER to prioritize spending. We have BARELY tried to start making these decisions, and it was a landmark move when CMS decided not to fund CT-colography for cancer screening. It simply hasn't proven its worth--period.

A QALY cutoff. Hey, you want expensive monoclonal antibody therapy known to extend dying by lung cancer for 8 weeks at a cost of a million bucks per year of life gained? Sorry, that's over the limit per QALY. Only if we assume infinite resources is it ethical to fund anything that "might help" or "barely helps" and in these settings only do you see things like the recent Annals of IM article arguing that terminal patients should be counseled against, but allowed to receive, futil code blue and icu services at end of life if they choose them. Huh? I am NOT giving worthless care to anyone, but I have all the time in the world to do things that may help or to comfort them. This may be cold, but we can't borrow forever. And if funds determine outlays, we have a simple budget neutral plan for our "base care."

At a minimum I think we should level and standardize paperwork issues across the health plans to vastly reduce overhead costs for everyone. A government is ideally suited to make this change.

To answer one of your questions Bill: the reason we can handle providing all the extra care when people get insured is because one reason our healthcare is so costly is ... extra capacity. And the remainder can come from ... blocking payment for unnecessary services--namely making our inefficient regions work like the efficient ones (or eat the costs themselves).

Bill Glasheen · Post by **Bill Glasheen** » Fri Oct 02, 2009 2:50 am

IJ wrote:
To answer one of your questions Bill: the reason we can handle providing all the extra care when people get insured is because one reason our healthcare is so costly is ... extra capacity.

Ian

We don't have extra capacity where we need it most - primary care. And right now, the uninsured inefficiently get their primary care in the ER. Throw those people where they belong - over with the primary care specialties - and you immediately run out of capacity.

Being in primary care isn't sexy, and it doesn't pay as much as the specialties. Some of that is going to have to change. And it'll take a long, long time to turn that ocean liner around.

The company I work for is getting research funds to develop the concept of a "medical home." This is where primary care MDs get paid more, and are given more responsibility. They get reimbursed by how sick their patients are, and the kinds of outcomes given the level of morbidity. It's complicated... which is why they leave it to the big boys to figure out.

But maybe one day we'll work it out.

And when/if we do, then primary care will be the place to be, and health care will make a turn in a better direction. The days of the hot shot specialists on TV will be gone, and we'll be back to Marcus Welby MD. Sort of...

- Bill

Jason Rees · Post by **Jason Rees** » Fri Oct 02, 2009 2:54 am

The company I work for is getting research funds to develop the concept of a "medical home." This is where primary care MDs get paid more, and are given more responsibility. They get reimbursed by how sick their patients are, and the kinds of outcomes given the level of morbidity. It's complicated... which is why they leave it to the big boys to figure out. But maybe one day we'll work it out.

Now that sounds like a research project worth funding!

IJ · Post by IJ » Sat Oct 03, 2009 2:45 am

It doesn't take that long to turn ships around, actually. Just like major fast food places can clean up beef overnight with a simple directive to their dependent suppliers, the government (and nobody else that I know of) can simply change the reimbursement rules and reduce payments for procedures and increase payments for people who spend a lot of time interpreting data and

I did tap off 6 liters of chylous ascites after a bedside ultrasound which was kinda cool, but I spend most of my time thinking and trying to get proceduralists not to kill my patients and waste money, so whenever they want to get around to it, they're more than welcome.

Hey, can we all agree that it's F'ing criminal that doctors have a stake in MRI centers (etc) they refer their own patients to? You think medicare gets more bills for MRI from these bleepity bleeps? Find out if your doctor has a stake in anything they're pushing, vote with your feet, and complain to the AMA this minute. It's not a profession if people are permitted to act unprofessional.

Jason Rees · Post by **Jason Rees** » Sat Oct 03, 2009 3:54 am

Hey, can we all agree that it's F'ing criminal that doctors have a stake in MRI centers (etc) they refer their own patients to?

Absolutely.

Can we make that illegal while NOT setting up a government-run medical boondogle? I sure hope so. I mean, the same scenario you described above in a financial business environment would violate a slew of ethics laws, I believe. Why is medicine exempt from this?

Rising Star · Post by **Rising Star** » Sat Oct 03, 2009 3:59 am

well I guess the fix wasn't in - NO Olympics for You! That was an expensive "sacrifice" for the president, first lady and oprah.

John

Bill Glasheen · Post by **Bill Glasheen** » Sat Oct 03, 2009 9:31 pm

..................NO Olympics for You!

Gene DeMambro · Post by **Gene DeMambro** » Sat Oct 03, 2009 10:40 pm

Got a problem with the President advocating for the Olympics coming to the US?

Gene

Rising Star · Post by **Rising Star** » Sat Oct 03, 2009 11:15 pm

Absolutlely! I love the olympics but it is NOT the president's, first lady's, tv talk show host's job to advocate for them. That is why we have a US olympic committee.

How many US tax dollars went into Michelle's/ Oprah's flight, the president's filght, plus all of the associated costs and flights......

One, if one were remotely intelligent, would think that the cult of personality would have at least one or two things here at home that need his attention. Maybe confer with his general in Afghanistan more than once every 70 days.

How many sons, daughters, husbands, wives, fathers, mothers died while he and michelle and oprah made that "sacrifice" to go to copenhagan?

John

Jason Rees · Post by **Jason Rees** » Sun Oct 04, 2009 3:23 am

Well... if Putin could bring the Olympics to Russia, I don't see why Obama couldn't try to bring them back to the U.S. Unfortunately, our scandal-ridden Utah performance, and the bombing in Atlanta have put a foul odor in the air as far as the IOC are concerned. I wasn't expecting too much.

Now, the first lady going over there and prattling on about how her daddy taught her this and that, and it all being such a sacrifice to travel to Denmark and hobnob with Oprah?

Puh-lease. I might view it as a trial to deal with Oprah in person, but somehow I think that's right up the 1rst Lady's alley.

And Oprah? Somebody's got a very inflated opinion of their self, and apparently they travel in packs.

Bill Glasheen · Post by **Bill Glasheen** » Sun Oct 04, 2009 4:43 pm

A tale of two asse... I mean cities. Which city would YOU want to visit to learn about their local culture?

Such a HARD decision for the IOC...

- Bill