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We Need to Design Health Care Reform That Puts Patients Before Profits

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Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#171

Post by pcwalton »

tptacek wrote: post #149
awinder wrote: post #145

Earlier quoted context omitted.

I mean I'm at 20% in 2 cost centers (ill give you back 3 single digits but not a digit more), and there's more math on how you actually save money in a single payer system than just those 2 things. I don't know where the average family low-deductible plan costs $500 (maybe with employer subsidies? again, not a fair comparison), but 20% is a lot more than the 5% the parent discussed.

I'm going to hold you to your own 17% number just to keep things simple. In Chicago, for a family of four, the lowest-priced ACA bronze plan, Blue Cross with a restricted network ("FocusCare") and a $15,000 family deductible, after zeroing out 17% of expenses, you are paying $976/mo. I think health insurance is very valuable, but can say confidently that the average family in Chicago does not view $976/mo with a $15k…

Doesn't your argument suggest that a functional national health care policy should focus on both controlling payer-side costs and provider-side costs? Like the Swiss system does—payer-side costs are capped as a fraction of household income, and provider-side costs are tightly managed so that the total economic burden remains reasonable.

To me it seems that both sides are presenting a false dichotomy where none need exist. We should bring our health care costs under control, and we ought to simplify Medicaid from a patchwork of state laws that are "mostly, kinda" universal to truly universal, like the Swiss system. I suspect that, in terms of raw dollars, Medicaid spending is already sufficient to fund basic health insurance for everyone who can't afford it; it's just distributed inefficiently and in need of reform. Replace the patchwork of state laws with a flat subsidy for those who can't afford basic insurance, and replace the punitive individual mandate with automatic enrollment.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#172

Post by kerkeslager »

tptacek wrote: post #168
kerkeslager wrote: post #161

Earlier quoted context omitted.

To do that math effectively, you'd have to look at which parts of a health insurance company's structure are essentially waste caused by health insurance being private, and zero all that, and I'd presume that's a large portion of premiums. The CEOs are just the most obvious example.

I don't have to do very complicated math to add up (or even wildly overestimate) compensation for CEOs, zero them, and see what that saves. I don't like that CEOs make that much money either, but why would I waste time on them? They're not the problem.

I'm saying that a doctor's contribution to society is a lot more than a health insurance CEO's and yet that is not reflected in their salary.

It wouldn't surprise me if doctor pay was a larger factor in healthcare costs. But doctor pay is an inherent cost of healthcare, and while we can certainly lower their pay, it's not entirely clear to me what a fair pay would be.

Health insurance CEOs, and indeed most of what a health insurance company does, are not only not inherent costs, but active blights on the healthcare system. A fair pay would be zero, with fines for literally killing people. So they're much higher priorities than doctors for the axe.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#173

Post by tptacek »

kerkeslager wrote: post #172
tptacek wrote: post #168

Earlier quoted context omitted.

I don't have to do very complicated math to add up (or even wildly overestimate) compensation for CEOs, zero them, and see what that saves. I don't like that CEOs make that much money either, but why would I waste time on them? They're not the problem.

I'm saying that a doctor's contribution to society is a lot more than a health insurance CEO's and yet that is not reflected in their salary. It wouldn't surprise me if doctor pay was a larger factor in healthcare costs. But doctor pay is an inherent cost of healthcare, and while we can certainly lower their pay, it's not entirely clear to me what a fair pay would be. Health insurance CEOs, and indeed most of what a…

These are arguments about making people feel better about the system, but not about making the system meaningfully better.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#174

Post by tptacek »

CharlesColeman wrote: post #170
tptacek wrote: post #66

The problem with US health care is that it costs too much. The elephant in the room in US health care costs is inefficiency on the provider side. Payer-side reforms have limited impact, because contrary to rhetoric from both sides of the debate, we could probably zero out administrative costs entirely and still deliver little more than a grocery store discount to American consumers. However we structure payment, we'r…

> The elephant in the room in US health care costs is inefficiency on the provider side. Payer-side reforms have limited impact, because contrary to rhetoric from both sides of the debate, we could probably zero out administrative costs entirely and still deliver little more than a grocery store discount to American consumers. Certain kinds of payer-side reforms (e.g. single payer) could allow the providers to be bul…

This is a very popular argument in favor of single-payer. But Medicare already has authority over the most expensive and intensive segment of the health care market and has not effectively "bullied" providers down. It's not my argument that a single payer system can't do this, but rather that it doesn't appear to matter whether you have single payer or not; either way, radical change will be required from providers, and those changes are not intrinsic to the payer system.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#175

Post by screye »

kerkeslager wrote: post #152
screye wrote: post #71

Earlier quoted context omitted.

I think engineers really underestimate the value of their work. An engineer's impact on a single person might be low, but at scale, it can add up to a lot. As noble as being a doctor is, their individual contributions can never scale beyond a few people. While I am at it, can someone explain why being a doctor needs a person to go through 4 years of undergrad in field completely useless in their domain ? > The entire…

> An engineer's impact on a single person might be low, but at scale, it can add up to a lot. > As noble as being a doctor is, their individual contributions can never scale beyond a few people. Nonsense. If you only scale into saving hundreds of users a few minutes each, you're maybe approaching one lifetime, and that's assuming that your time saving actually improves those users' lives. The vast majority of enginee…

> Meanwhile, some doctors absolutely make contributions that scale, such as finding cures or vaccines, preventing spread of infectious diseases, or discovering ways to detect diseases earlier.

and many engineers have invented machines that have saved millions of lives. Let alone the fact that most of the things you mention were discovered either by academics or pure science researchers.

Doctors : Medical scientists :: Engineers : Physicists & mathematicians.

Doctors aren't doing the inventing. They are applied practitioners of their profession. The sycophancy around worshiping doctors is one I can never get my head around. Sure, it is a difficult job to learn and an essential part of any system, but just being the medical profession doesn't give a doctor any moral high ground in their choice.

Being in India, the biggest contributors to saving lives have been policy makers. Funding access to clean water, electricity and roads are far bigger life savers than someone who can do surgery. Google is probably saving more lives by letting doctors web search symptoms, than entire families of hospitals.

I have no delusions about my work. I do it because I like it. I would still do it if it was live saving, or completely irrelevant to society at large.

But, raising certain professions to an innate moral high ground makes no sense to me. Be it doctors, fire fighters, veterans or first responders. If a person needs continuous approval from society to do their job, then they should not be doing it in the first place.

That being said, I will always give every honest job a minimum level of respect and appreciate both hard work and tenacity. So, I am not advocating for being an ass to doctors. However, I respect those values, not some innate virtue of their profession.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#176

Post by tptacek »

pcwalton wrote: post #171
tptacek wrote: post #149

Earlier quoted context omitted.

I'm going to hold you to your own 17% number just to keep things simple. In Chicago, for a family of four, the lowest-priced ACA bronze plan, Blue Cross with a restricted network ("FocusCare") and a $15,000 family deductible, after zeroing out 17% of expenses, you are paying $976/mo. I think health insurance is very valuable, but can say confidently that the average family in Chicago does not view $976/mo with a $15k…

Doesn't your argument suggest that a functional national health care policy should focus on both controlling payer-side costs and provider-side costs? Like the Swiss system does—payer-side costs are capped as a fraction of household income, and provider-side costs are tightly managed so that the total economic burden remains reasonable. To me it seems that both sides are presenting a false dichotomy where none need e…

I'm receptive to all reforms! Reforming health care administration is worth doing; even if it doesn't make health care "affordable", these are big numbers we're talking about, and percentage-point changes in administration costs still generate money we can use on other things.

Where we get into trouble is when we start contemplating radical reorganizations of the existing system without a clear goal or path to achieving that goal. So I could be receptive to single-payer if there was some clear idea of how it would get our costs in line with European systems. But no such clear idea is in evidence; rather, Democrats seem to believe that reorganization will somehow automatically solve that problem. More cynically --- and realistically --- I believe Democratic single-payer advocates think that once the government becomes the single payer, nobody is going to care about the costs anymore. I think there's an element of truth to that, but I'm not one of those people; I care that we're paying 2-3x what we should be paying.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#177

Post by thaumaturgy »

tptacek wrote: post #164
thaumaturgy wrote: post #158

Earlier quoted context omitted.

> That's fine, but it doesn't address the fundamental problem of US health care costs, which is --- regardless of "who pays" --- "why does it cost so fucking much". A doctor named David Belk set out to find answers to this question. He presented what he found at http://truecostofhealthcare.org/ . You can start with the introduction ( http://truecostofhealthcare.org/introduction/ ) or skip straight to the conclusion (…

I don't have an opinion about profit margins in the US health care system and am receptive to arguments that profits in the system are themselves exorbitant (it's Rayiner who consistently argues for perspective about comparative profits; ironically, Rayiner supports a national health plan, and I oppose it). My argument is orthogonal: it's that there is a payer side of the system and a provider side, and the national…

Sure, and that's one of the reasons I like Belk's site: he tries to explore more facets of the overall US health care clusterfuck than most other researchers and journalists.

For the hospitals' portion of the mess, he finds that despite an overall decline in hospital stays [1], the amount that hospitals bill over what they actually collect has grown dramatically [2]. This in turn is caused by differences in incentives between Medicare/Medi-Cal and private insurance companies; private insurance companies are less motivated to drive down costs, and even have some incentives to pay hospitals more than Medicare/Medi-Cal would for the same services.

Hospitals likewise have had steadily growing profits overall (in the 5% to 8% range) over recent decades, although most US hospitals are non-profit business entities. (This doesn't mean they don't make money, of course.)

This really funky interplay between governmental health insurance, private health insurance, and hospitals is the main driver of the shocking, headline-grabbing bills people receive. They aren't the prices the hospital is expecting to actually collect, they're the prices that hospitals have invented in the hopes of collecting 30% of it from Medicare, and private insurance companies are playing along because it gives them a justification for raising their pricing for coverage. In a sense, a lot of what people are arguing about is phantom prices.

Unfortunately, uninsured and under-insured get caught up in all this absurdity and that ends up driving around 60% of bankruptcies [3]. And while there are often arguments that hospitals have to charge more because there are more people unable to pay their bills, the number of uncollected bills hasn't really changed for a long time [2].

Thus a lot of the discussion around this issue ends up coming back to "greedy insurance companies" because they really are a major contributor to the problem. Prescription drug pricing likewise affects a disproportionate number of fixed-income people (whether retired or disabled).

I'll try to keep yours and ~rayiner's different positions in mind in the future.

[1]: http://truecostofhealthcare.org/admissions_data/

[2]: http://truecostofhealthcare.org/hospital_financial_analysis/

[3]: http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bill...

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#178

Post by CharlesColeman »

tptacek wrote: post #174
CharlesColeman wrote: post #170

Earlier quoted context omitted.

> The elephant in the room in US health care costs is inefficiency on the provider side. Payer-side reforms have limited impact, because contrary to rhetoric from both sides of the debate, we could probably zero out administrative costs entirely and still deliver little more than a grocery store discount to American consumers. Certain kinds of payer-side reforms (e.g. single payer) could allow the providers to be bul…

This is a very popular argument in favor of single-payer. But Medicare already has authority over the most expensive and intensive segment of the health care market and has not effectively "bullied" providers down. It's not my argument that a single payer system can't do this, but rather that it doesn't appear to matter whether you have single payer or not; either way, radical change will be required from providers,…

Those are two separate questions: whether the payer has enough power to bully the providers into reforming, and whether it actually chooses to use that power to do so. Medicare may have the power, but may not have the will to use it (for instance, IIRC, it's forbidden by law to use its market power to secure better drug prices). A payer reform like single-payer will get us a lot closer to solving provider cost problem, but it won't get us all the way there.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#179

Post by rayiner »

claudeganon wrote: post #136
tptacek wrote: post #130

Earlier quoted context omitted.

You're using "account for their costs" in a different sense than I think Rayiner meant. When Sanders "accounts for his costs", he means that they've added up the total projected costs of their plan and then accounted for it with tax revenue. That's fine, but it doesn't address the fundamental problem of US health care costs, which is --- regardless of "who pays" --- "why does it cost so fucking much". If all we do is…

As I mentioned to Raiyner, you should really read Tim Faust’s book to understand how single-payer can drive down costs, but I’ll highlight this from one of his articles: “ As the sole purchaser, the federal government is immediately able to set just prices for health care services (for example, by negotiating the cost of drugs). With the weight of the full cost of health care falling squarely on its shoulders, it has…

These are just general concepts. It’s on the same level as “the market will drive down prices because hospitals and insurers will compete.” What I’m talking about is actual data about what is entailed, for example in “bilk[ing] payers.”

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#180

Post by kerkeslager »

TuringNYC wrote: post #166
kerkeslager wrote: post #159

Earlier quoted context omitted.

Okay. So maybe the multiplier of my salary to get a doctor's salary is 5 or 6 instead of 2 or 3. The multiplier of my salary to get a health insurance CEO's salary is also now, what, 200 or 300 instead of 100?

Actually, my point was the opposite -- I was noting that software engineers dont make enough compared to doctors and deserve more given the major SWE downsides: - SWE: Much of the premium might be CoL premium - SWE: There is a downward slope on earning potential - SWE: No cartel and constantly expanding pool of workers I'd argue that SWEs should make more given all these negative aspects.

Okay. It's not a really a point I care that much about, but I'd argue that this is a very SF/NYC-centric viewpoint.

- SWE: Much of the premium might be CoL premium

There are non-SF/NYC software jobs. Before I was a freelancer, I worked only one salary job in NYC. The rest of the time I worked and lived in much lower-CoL areas. And as a freelancer I work remote, getting paid NYC/SF money in a much cheaper place.

- SWE: There is a downward slope on earning potential

There may be a downward slope on earning potential, but that's in part because the SF/NYC markets bump you up pretty high pretty early, without much real justification. These places seem to fetishize the young hotshot "10x" programmer who is willing to work 70 hour weeks, but the reality is that that isn't sustainable, and the work done by kids isn't actually very high quality. That only works for a fail-fast startup model, but most companies outside the NYC/SF bubble aren't actually like that. There are plenty of old greybeard programmers working boring jobs at Dunder Mifflin-type companies in the Midwest, making wages increasing by 3% over inflation every year. Maybe they never peak as high as their SF/NYC counterparts, but they're still making more than a lot of other jobs in their areas. And the workloads of these jobs themselves are more sustainable.

- SWE: No cartel and constantly expanding pool of workers

There's also an expanding job market. Sure, there are cyclical downturns, but the overall trend is up.

One thing that trips a lot of people up is a failure to specialize. If your job is writing Django/Angular apps, that only gets so difficult, and there's not really a reason to pay for someone with more experience beyond a certain point. But Django/Angular apps aren't the peak of software engineering--there are much more complex systems out there which actually do need someone with more experience. I see a lot of people hit the point where they can't progress further with LAMP/.NET/whatever-common-stack and get stuck instead of going back to school or finding a job that will teach them cryptography or networking or FPGA programming or whatever.

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