Medicare Whac-A-Mole

Why health care price controls always fail

(Page 3 of 5)

In 1985 Congress commissioned a review of the DRG system. But rather than stick to a retrospective, the authors of the report expanded its scope, using it as an opportunity to push for expanded physician price controls. The theory was that DRGs, focusing only on hospital payments, hadn’t gone far enough. According to Smith’s Medicare history, the authors of the review believed “the most viable approach…was to aim at increasingly global control of physician payments.” A program passed on a promise to avoid control of the medical system was now looking to control its entire payment structure.

Who was behind this push for global control? Joseph Antos, an American Enterprise Institute health policy scholar who served as a senior economist in the Reagan administration —a role he describes as the “designated health and everything else person”—attended many senior staff meetings during which the new system was drawn up. “This was a group that consisted of high-level people, often political appointees from all sorts of different agencies,” Antos tells me. “I don’t think many of them were health policy experts. I know none of them were economists.” 

The system they were planning would become known as the resource-based relative value scale, or RBRVS. It attempted to divide physician’s services into roughly equal work units and make payments accordingly. The assorted high-level officials had a naive confidence in their ability to accurately align the amount of work that went into a procedure with the amount of payment a physician received. “They knew that there was a problem paying physicians,” Antos says. “They thought they knew what the problem was. This was going to be a new system that was going to rationalize the old system.”

Antos, the only economist in the group, wasn’t so sure. And so he began to ask questions: “How does the government know what the relative values should be? How is this related to any market-clearing process that anybody’s ever known?” One idea was to set prices by committee. Antos pointed out that “asking committees of doctors to guess how much work is involved in something is the same thing as just setting prices.”

In an October 2010 essay for The American, Antos described the initial plan as being “based on academic theory with its roots in the Soviet Union.” Just as the Soviets made all economic decisions—how many tanks to build, how many jackets to sew, how much food to produce—through central planning, the RBRVS system is an effort to centrally plan medical prices. But as in the Soviet Union, those prices are not informed by market-based signals, which are generated by the interaction of supply, demand, and willingness to pay. In particular, the RBRVS system ignores how much value a patient receives from a service.

Thanks at least in part to Antos’s questions, 1986 came and went with no major overhaul of the physician reimbursement system. But Antos eventually left for a new post. And in 1988 researchers at Harvard University finalized a study that would bring a modified form of prospective payment to physicians. In December 1989, as part of an omnibus budget proposal, President George H.W. Bush signed the RBRVS system into law. It would take effect in January of 1992. 

Antos, who eventually transitioned to a senior position at the Health Care Financing Administration (HCFA, now the Centers for Medicare & Medicaid Services within the Department of Health and Human Services), was put in charge of implementing the system—not in spite of his skepticism but because of it. “I had a long connection to it, so I understood it,” he says. “And [HCFA Administrator Gail Wilensky] didn’t mind that I was against it, because she was an economist and also agreed that it wasn’t going to work.”

The Socialist Calculation Problem

Why would an economist be so skeptical of the system? Even from a purely technocratic perspective, it is an enormous challenge. Antos warns of the “technical difficulty of creating a prospective payment system that wouldn’t totally screw everything up.”

But the problem goes deeper than that. Medicare’s twin payment schemes are inevitably beset by what George Mason University economist Arnold Kling calls “the socialist calculation problem.” The bureaucrats in charge of setting prices have to come up with a rational basis for the prices they set. They have to be justified, somehow, which is where the complex rate-setting formulas come into play. But without price signals, the result is almost always an arbitrary formula based on a limited, imperfect set of factors. When all is said and done, says Kling, “it’s just a made-up formula. It has to be.” 

The other problem is that any payment system inevitably ends up being manipulated by savvy payees. “You price on the basis of one thing, but then people optimize their behavior to that thing,” says Kling. In a sense this is the primary job of health care administrators: to understand payment systems and squeeze every possible dollar out of them. 

In the wake of the two payment reforms, hospitals began to manipulate the system through “upcoding”—systematically shifting patients into higher-paying DRGs. Research by economists at Dartmouth University suggests that during the early 1990s, hospital administrators figured out ways to substantially increase the number of Medicare cases they billed to higher-paying DRGs. Payment games continue today. In October the Senate Finance Committee released a report accusing several large home health care companies of abusing Medicare’s payment rules by pushing employees to perform extra therapy visits, thereby qualifying for Medicare bonus payments, even when those visits weren’t strictly necessary. But for many health care providers, that’s the business. Hospital administrators “are people whose job it is to game the system,” Kling says. “They know every little detail of the rules.” 

Playing by the rules, and getting the most out of them, becomes the focus. Over time, the rules cease to guide the game and instead become the purpose of the game. Activities that are coded and paid for become the activities that providers do the most. The system encourages covered procedures, such as surgeries and child delivery, while discouraging doctors from spending time in nonpaid activities such as emailing patients or monitoring health data collected electronically at home by the patient. The provision of care bends to fit the shape, however quirky, of the payment rules. 

Which may explain why controlling physician payments failed to restrain the growth of Medicare spending. As Antos expected, the system did not work. The RBRVS system took effect in 1992. By 1997 Congress had the mole mallet out once again. 

The Unsustainable Growth Rate

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  • ||

    I hate the "as we know it".

  • Suki||

    +1 for The Drake

  • Barack Obama||

    Let me be clear.

    When I am re-elected, I will end the "as we know it" as we know it.

  • Half of America||

    +4 more years!

  • Edwin||

    Actually the "as we know it" is the best part here. It implies that they merely want to change it, not completely get rid of it, which is the accusation the Democrats' always try to levy to make the Republicans look like extremists.

    We don't want to end it, and if we do, we want to replace it with some other, better voucher system or something.

  • Suki||

    Morning links at 9:04

  • WTF||

    Jesus really must love Tebow. Rumor has it, he's dating her.

  • The Other John||

    She needs lots of "Sexy Times"
    He doesn't do "Sexy Times".

    It won't last

  • TT||

    I pray for her satisfaction.

  • Your Congressperson||

    Until Medicare as we know it is ended, Medicare as we know it will not end.

    I'm counting on your vote in November.

  • ||

    As someone who spent years helping to make payer software and grouper software--for hospitals and hospital chains all over the country--excellent article Suderman!

    "Since the birth of the entitlement, a parade of legislators and bureaucrats has been playing billion- and trillion-dollar games of Whac-A-Mole with Medicare, knocking down spending with an elaborately constructed set of technocratic payment schemes in one area only to see it rise back up in some other part of the system."

    I just wish someone could persuade you to see that spiking private insurance rates are also a function of this Whack-A-Mole process.

    When we cut Medicare payments to hospitals, the cost of caring for those patients doesn't simply disappear. Those costs show up in all the places you mentioned--and they also show up in much higher premiums for private insurance...

    Since hospitals make up for the Medicare payment shortfall by gouging private insurers. This is why PPOs so strongly discourage their members from going to hospitals with which they don't have a contract.

    This is why when a privately insured patient is admitted through the ER in a struggling inner-city hospital, it's all high-fives around the business office.

    I remember when they were debating ObamaCare, and our politicians first started commenting that it was less expensive for the government to put people on Medicaid than it was to give them money to buy private insurance. Of course price controls make things cost less for the people who benefit from them!

    It's the privately insured and uninsured, those are the patients who have to make up for all those missing Medicare and Medicaid payments--they're the ones who are left holding the bag.

  • ||

    Yep. And the mandated benefits of the 50+ states and territories that all administer insurance differently on top of federal rules and mandates.

    Visit the headquarters of any insurance company and you will see floors and floors of corporate lawyers, analysts, accountants, actuaries, clerks, and programmers trying to keep up with the government imposed busy-work.

  • Gerholdt||

    Not to mention the data center. When I worked for a health care provider, we had a process called "the adjudicator" that ran all night, every night, to assign the share of every charge, on every bill, for every patient, to Medicare/Medicaid, a private insurer, or the patient. We're talking at least six figures for the servers, storage, and database licenses, and then the ongoing cost of data center space, operators, cooling and electricity.

  • ||

    "We're talking at least six figures for the servers, storage, and database licenses, and then the ongoing cost of data center space, operators, cooling and electricity."

    I was working support one day, and this guy calls me up from one of the hospitals running our software.

    He says, "I probably shouldn't call you about this, but my server shut down. I don't think it's from your software though; I think it's an electrical glitch. I just wanted to log this in just to let you guys know--and get it into the queue."

    I said, "Well, why do you think it's an electrical glitch?"

    And he says, "Well, our air conditioning system broke down about an hour ago, and we have some guys here to fix it--it probably won't take them more than a few hours--and I figure whatever caused the air conditioning to go out probably shut off the power to the server too."

    This guy's running millions of dollars in hardware serving a major metropolitan university healthcare system with like 20 satellite centers--and no air conditioning?

    Okay!

    I liked working the software side a whole lot better.

    Anyway, you're absolutely right about those data centers. The data centers our software required were huge--bigger than what you get for a lot of banks. The amount of data being generated by a major hospital on an average day is amazing. The financial transactions are incredibly complicated.

    And even what should be standard practice across Medicare, you'd think, differ according to the intermediary you're using. And it never ends. Every quarter the Federal Register adds more things to think about--changes things from payer rates to NCCI.

    It's a never-ending nightmare.

  • adam||

    Serious question: if Medicare/Medicaid patients are money-losers for hospitals, why don't they just drop the programs? I've heard that many doctors have dropped Medicaid and some Medicare, but haven't heard of any hospitals doing so.

  • Gerholdt||

    They are required to accept Medi patients in order to keep their license to do business. If there aren't enough patients who can pay through private insurance or otherwise, they go bankrupt, like D.C. General in 2001.

  • ||

    "Serious question: if Medicare/Medicaid patients are money-losers for hospitals, why don't they just drop the programs? I've heard that many doctors have dropped Medicaid and some Medicare, but haven't heard of any hospitals doing so."

    My experience is a little dated, but this part I doubt has changed...

    I think it's ultimately about accreditation for a lot of them. In many places, you can't get your hospital accredited unless you have a Medicare contract.

    There's also the thing about not being allowed to refuse service in an ER based on the inability to pay for services. So, if you're going to have to provide services to people coming through the ER anyway, and a lot of them have Medicare and Medicaid, then you might as well get paid something, even if, like in Medicaid, it's typically only 12.5 cents on the dollar billed.

    This is mostly just a problem for inner-city hospitals, where the local population has a relatively low percentage of privately insured patients. Using Southern California as an example, it's not the hospitals in Irvine and the better parts of Orange County that have a problem. They have more than enough private pay patients to charge to make up for all the money they lose on Medicare and Medicaid patients.

    It's your King Drew Medical Center and County USC, in places like what used to be called SouthCentral LA, that have these problems. Because a very low percentage of their patient census has private insurance, and they can't make up for all the money they lose on Medicaid patients on volume!

    So, as long as you have enough private pay patients that you can generate enough money to cover the losses on the people on the government program, it doesn't really matter what your sources and uses analysis says--you might as well get paid for the Medicare and Medicaid patients you're serving. What matters is that your revenue sheet balances.

    Keeping Medicare and Medicaid patients out is basically the whole strategy of a PPO (when it comes down to it). But if you're a hospital in a location with a demographic where very few of your patients have private insurance, then, cutting yourself off from 90% of your customers isn't about to save the hospital either.

  • ||

    Two other quick points:

    1) Doctor's get paid pretty well for Medicare and Medicaid services, and doctor's who generate a lot of money for a hospital need a place to do surgeries and refer their patients.

    If you're a hospital, and you've got a doctor that's generating a lot of income for your facility by referring a lot of privately insured patients to your facility, you want to keep that doctor happy!

    Telling him that he can't make any money on his Medicare and Medicaid patients because you won't accept them?

    Makes doctors unhappy.

    Patients will basically go to whatever facility their doctor tells them to go--and when you hear hospitals talking about marketing, they're mostly talking about marketing to doctors.

    2) I forget the second point. It'll come back to me.

  • ||

    I remember!

    2) When you're a hospital chain--particularly one that's publicly traded. You need to grow.

    Your stock price reflects a certain p/e ratio, and that ratio represents your growth prospects. What do you do once you've grown nationally to the point that you've basically soaked up all the private pay patients you can given your efficiencies, market position, etc.?

    You have to have more growth if you want to justify your p/e.

    If your in-place costs are already being covered by premiums at your HMO, etc., then adding more money just looks like profit. In other words, like a hospital in Irvine, where they have more than enough privately insured patients to cover their losses, an HMO that's already covering its costs with private pay money is tempted to add revenue by tapping the Medicare/Medicaid market.

    It always seems like it's gonna work that way anyway. I've seen chains of hospitals break down badly after deciding to take the plunge in Medicare and Medicaid patients.

    HealthSouth, Columbia/HCA, Tenet Health...

  • ||

    Serious question: if Medicare/Medicaid patients are money-losers for hospitals, why don't they just drop the programs?

    As someone who works for a hospital, it comes down to a couple of things:

    (1) You can't turn anyone away - the ER is always open to everyone. So if you are going to have to take them anyway, you might as well be in MA so you can get paid inadequately, rather than not at all.

    (2) Fixed costs. Hospitals have enormous fixed costs. Even a patient that you lose money on at the margin is helping cover your fixed costs.

  • Barack Obama||

    Of course price controls make things cost less for the people who benefit from them!

    Let me be clear.

    I'm glad you get it.

  • ||

    "Of course price controls make things cost less for the people who benefit from them!"

    Let me be clear...

    The problem is that the overwhelming majority don't benefit from price controls.

    It's like...a legacy UAW worker, who gets paid $70 an hour to screw in lug nuts.

    Society would be better off if people weren't overpaid through a union's monopolization of access to a workforce...

    ...but who would argue that the UAW worker who gets paid $70 an hour for screwing in lug nuts isn't better off for being overpaid to screw in lug nuts? Some people are better off for being overpaid to do very little.

    Likewise, there's no denying that some Medicare/Medicaid patients are better off in some ways because they don't have to pay for much of their medical bills--especially the ones who don't pay much in the way of taxes.

    The other 95% of us? Not better off because of Medicare/Medicaid.

    Hope that's clearer.

  • ||

    I'm a primary care physician who started in practice in 1982 in the middle of the government's failed attempt to control spending by price controls and HMOs. Older physicians at the time waxed nostalgic for the golden (and I do mean golden) days right after 1965 when they had a blank check to do anything they wanted. A lot of fortunes were made in those days. Yes, medicine still pays quite well, but there are hurdles and hoops to jump. The basic principle, that the consumer (patient) has no say in the transaction, still causes runaway medical inflation. When you're trapped in a hole, the best thing to do is stop digging.

  • Concerned Citizen||

    My wife works for a medical billing software company. She sees what a clusterfuck the gov't has made of health insurance and is dumbfounded by the people who believe the gov't will make things better.

  • Gerholdt||

    Gee whiz! Incentives work. The Market works. We've known this even before Adam Smith characterized it as "the invisible hand". Price controls are like King Canute ordering the tide not to come in. And yet, like Kipling's bandar-log, some people believe the world can be changed by magical words. Capitol Hill is not Hogwarts, Reid is not Dumbledore, Obama is not Harry Potter, and oh yeah, this is reality, not a bleeping movie.

  • Tony||

    Medicare costs per beneficiary have risen substantially, but at a lower rate than private insurance. Its payment system is too open-ended and could use significant reform, but you can't escape the fact that Medicare-like programs the world over are quite a bit cheaper than our semi-privatized system.

    All privatization schemes for healthcare in the US will not do anything about the actual costs (the costs of healthcare), but will only create paper savings for government.

    Universal coverage is inevitable, you might as well deal with it. The only thing standing in the way is the profit interests of private companies.

  • Gerholdt||

    In the socialized medicine system, physicians do not have crushing student loan debt and huge malpractice insurance premiums to cover.

  • Tony||

    What's your point? We should make healthcare cost prohibitive for many people in order to provide welfare for doctors?

    I'm all for subsidized higher ed too. Malpractice insurance costs are not significant in the big picture.

  • Sevo||

    "I'm all for subsidized higher ed too. "

    Which, shithead, will mean even more expensive higher ed.
    Go back to your commix; they're something you might understand.

  • Tony||

    How? Government subsidized healthcare insurance is universally cheaper than private insurance, which is why most of the civilized world has gone that route.

  • Concerned Citizen||

    There is no private insurance, not when gov't mandates what it must cover and what it can charge customers.

  • Tony||

    No evidence means you don't get to make any claims.

    Libertarianism can't sustain itself on assertions that if only the world were perfectly libertarian everything would be great.

  • Edwin||

    He never said that, he just pointed out that your universal claim that "free market" insurance is more expensive, by pointing out that it is the farthest thing from free market

    And all this avoids the fact, that while you're right in terms of per-customer costs, Tony, medicare is LIKELY TO BANKRUPT US

    Maybe we could switch to a means-tested voucher instead?

  • ||

    Having lived and worked under several "government subsidized" medical systems, I have a couple of comments on their "low cost:"

    (1) Personnel are often quite restricted in what they can earn. While that may sound "fair," keep in mind it also often leads to less qualified personnel delivering health care services.

    (2) Service is invariably slower. I have had two friends die waiting for prostrate cancer treatment -- treatment they would have gotten early enough for a cure in the U.S. The extra demand one would expect for a "free" service evaporates as people give up trying to get care or go to a country where they can get care quicker. The travel costs usually are not covered by the national insurance plan.

  • ||

    Do you even READ the other posts before you comment? Yes Medicare costs have risen at a lower rate than private insurance - BECAUSE THE MEDICARE COSTS ARE FORCED ON THE PRIVATE INSURANCE PATIENTS, as pointed out above.
    "Universal coverage is inevitable, you might as well deal with it." Death is inevitable, but I still spend 6 - 10 hours a week working out to at least delay it.
    Once again I say - it's almost impossible to tell a spoof "Tony" from the real Tony. You have become a caracture of yourself.

  • Tony||

    Most economists who have published on this subject don't think cost shifting is a significant factor, if it exists at all. There's little or no empirical data that it occurs, and it may not make sense conceptually. (If private providers had the ability to increase revenues through price hikes, they would have done so regardless.)

  • ||

    Most economists who have published on this subject don't think cost shifting is a significant factor, if it exists at all.

    The studies I have seen looked at cost-shifting from uninsured patients, which is a relatively small problem (thus undercutting the argument for universal health care).

    Cost-shifting from the larger number of insured patients who you lose money on at the margin? Not insignificant.

  • Tony||

    But think about it conceptually... I'm constantly amazed by market worshipers putting so little stock in supply and demand. Same with taxation: It's not supply and demand that determine prices, I'm told, it's how much government is taxing employers, who apparently have are at liberty to ignore supply and demand and charge whatever they want.

  • Sevo||

    Tony|12.13.11 @ 12:13PM|#
    "I'm constantly amazed by market worshipers putting so little stock in supply and demand."
    No, you're simply an ignoramus who doesn't have a clue.

    "Same with taxation: It's not supply and demand that determine prices, I'm told, it's how much government is taxing employers, who apparently have are at liberty to ignore supply and demand and charge whatever they want."
    And this collection of bullshit proves it.
    Did you imagine there was a coherant thought buried in there, shithead?

  • ||

    "But think about it conceptually... I'm constantly amazed by market worshipers putting so little stock in supply and demand."

    Looks like some semantics here, Tony.

    When you say "supply and demand", what are you talking about exactly?

    Are you talking about voters? Because voters aren't the same things as supply and demand. Voters are sometimes people trying to override supply and demand. The politicians voters vote for are sometimes trying to override supply and demand.

  • Tony||

    I'm saying if providers could increase revenues by raising rates for private payers, they would have done so as much as possible prior to reductions in payments by public programs. That's assuming maximizing profit is the main motivator--as it generally is in a market--though nonprofit hospitals do complicate the picture (not enough to say cost shifting exists substantially).

    Generally prices are determined by supply and demand, no? That's true even if government subsidizes demand (thereby lowering prices for individuals). I'm constantly asked to believe that this econ 101 reality is shoved aside by a modest increase in income tax rates or the like, because prices apparently are determined by the supplier only and customers are at their mercy and have no say in the matter.

  • ||

    The problem is that the program you're championing isn't insulated from the private pay side. That's what I don't think you understand.

    The price of private insurance--and the price of heart surgeries, for instance, to private pay patients in hospitals--is a direct function of the un-reimbursed costs of Medicare and Medicaid patients.

    Just because Medicare and Medicaid patients don't have to pay much for the services they get under Medicare and Medicaid--doesn't mean that the government pays for those costs either! Those costs go un-reimbursed!

    When you're cutting payments to Medicare and Medicaid, you ARE necessarily raising them for private pay patients. When you flood Medicaid with more patients--which ObamaCare is doing--you ARE necessarily raising the cost of insurance and care for private pay patients.

    Some of those people can't afford that care anymore. That's the way it happens with supply and demand too! Nobody said that supply and demand means that everyone will get what they want at a price they like.

    Supply and demand means that sometimes there isn't enough supply to go around at the price everyone can afford--and some people have to go without! That's one thing if the commodity in question is a result of crop failure or a lack of production for some reason or some other real cause.

    But when the reason healthcare costs so much is because the government is artificially pumping the price of healthcare up--by effectively forcing insured and uninsured patients to cover most of the costs of people on government programs? Government programs which allegedly exist to keep healthcare accessible to people who can't afford it?

    Then you're not talking about people being excluded because of supply and demand--you're talking about people being excluded because of government interference in the market for healthcare.

  • Tony||

    You're just saying that there is cost shifting when I said there is scant empirical data to support it and it makes little sense conceptually. So provide a cite or we're just making competing assertions.

    Healthcare costs so much in this country because it is a business--the system prefers that people are unhealthy rather than healthy. If your primary goal is increasing the quality and access to healthcare (and it should be), then healthcare as a private business just doesn't work.

  • ||

    Nonprofit hospitals, including facilities owned by state and local governments, account for about 80 percent of acute-care hospitals in the U.S., according to the Wall Street Journal.

    ----Right Wing Huffington Post August 10, 2011

    And if profit seeking is the problem, why have so many non-profit hospitals under so much pressure, Tony?

    With more and more nonprofit hospitals feeling financial pressure, an increasing number are merging with larger outfits or selling themselves to for-profit companies, the Journal reports. There were 72 deals of this kind last year, the most since 2001, and already there have been another 55 transactions in 2011.

    The hospitals Medicare and Medicaid hurt the worst? Are the ones serving the poorest communities in our country, who are most dependent Medicare and Medicaid patients!

    The only solution they can find is to merge with a for-profit hospital. If it weren't for for-profit hospitals, there would be a lot fewer hospitals with emergency rooms for poor people to go to, that's for sure...

    I know your intentions are good, but you need to stop. The way you--and a lot of people like you--are thinking is hurting a lot of people.

  • ||

  • Tony||

    My thinking is that healthcare should be a right, and I don't care all that much how that becomes a reality.

  • ||

    You don't care about how many people suffer?

    You don't care if more people would get more and better care at lower cost by way of capitalism?

    If I thought my ideology was causing people to suffer, I'd change it.

  • ||

    If you means-tested Medicare and Medicaid, and then stopped requiring private hospitals to treat Medicare and Medicaid patients--unless they came through the ER...

    Just that would make it better for poorer people--it would make it better for just about everybody!

    There needs to be a private option--and right now there isn't one.

  • ObamneyCare hater||

    Tony-
    As a Doc, I am continually amazed at how laypersons such as yourself think the EVIL Doctors and Health Care Providers only care about keeping people unhealthy. The sad fact my friend is that most people KEEP THEMSELVES unhealthy. Primarily because they don't pay for their own healthcare. No cabal exists between docs and BIG PHAMRA. We don't sit around contemplating how to keep people unhealthy. You and your ilk are simpletons. Have you ever heard of risk factor modification? Smoking cessation? Vaccines? People age. When they age, they get sicker. Americans exercises little and eat lots. hence we are fat and unhealthy. Do you get it yet TROLL?

  • Sevo||

    Concerned Citizen: "She sees what a clusterfuck the gov't has made of health insurance and is dumbfounded by the people who believe the gov't will make things better."

    Dan: "When you're trapped in a hole, the best thing to do is stop digging.

    Followed by shithead: "Universal coverage is inevitable, you might as well deal with it."
    Yep, that's some shovel you got there, shithead.

  • ||

    Costs are going up because the waste of the socialized part of the market is being shifted to the privatized.

    Once this process is 100% complete there will be no more de facto subsidy, at that point the shoddy state of socialized medicine will become even worse. Just like in Canada and the UK.

    The result will be more needless deaths. Not just for the U.S. People in Canada will no longer have the easy option of driving down to the states to get care to avoid dying on a waiting list.

    The solution is to reduce the share of the inefficient sector, and free up the more efficient sector.

  • ||

    lol, the rich get richer and everyone else jsut gets stepped on.

    www.AnonSurfing.tk

  • ||

    I am not an economist, so I appreciated the rundown of the bad history of Medicare, BUT nowhere in any of this did I see a solution. I do have some questions that maybe someone could answer.
    1. Government is hugely inefficient; how much of Medicare(taxes from workers)go to pay for its' involvement in the health care system? Wouldn't it be cheaper to direct those dollars to either direct pay, or private insurers?
    2. Are medical co-ops a viable solution for any kind of coverage?
    3. Quite awhile ago I had a procedure, the tests for which cost over $17,000. The price for that is probably double now. Everyone knows that there is unnecessary testing going on (ostensibly to keep medical practitioners from being sued). If it was possible to rein in the frivolous aspects of some medical lawsuits, how much could be saved?
    4. I personally know 3 people that have suffered from hospital infections from surgeries. None in the same hospital some not even in the same state. Wouldn't public knowledge of these occurrences cause patients to leave said practitioners and force the hospitals to review or change their dirty habits? Then market forces would demand change wouldn't they?
    4. What is at the core of making just the costs of providing medical care more realistic? An office visit (without complicated diagnoses)for an uninsured person used to be about $25. Now it's almost $200. It can't be inflation can it? We're told by our so honest government that inflation is under control. What makes medical care so expensive?

  • Tony||

    Government is hugely inefficient; how much of Medicare(taxes from workers)go to pay for its' involvement in the health care system? Wouldn't it be cheaper to direct those dollars to either direct pay, or private insurers?

    No, as your assumption is wrong. Government is not all that inefficient, and has demonstrated in every single advanced economy that centralized systems of universal coverage cost about half what the US's more privatized system does per capita. It's always going to be cheaper because administrative costs are not multiplied and there is no profit factor.

    What makes medical care so expensive?

    The short answer is because of the incentives that exist in a private system. Providers, insurance companies, and drug makers are there to make a profit, not make people healthy.

  • Auric Demonocles||

    Providers, insurance companies, and drug makers are there to make a profit, not make people healthy.

    Just like distributors, grocery stores, and farmers are to make a profit, not make people full. This is why food is unaffordable.

  • Tony||

    Apples and oranges. I should say, apples and CT scans.

  • ||

    Government is not all that inefficient

    The former Soviet bloc salutes you, comrade.

  • ||

    Government is inefficient at every thing. 'Costs' are lower in socialized systems per person because of the level of care provided per person, if at all. You do not want to have cancer in the UK or Canada.

    In the US the socialized part is shifted to the privatized.

    Profit is what makes business sensitive to consumer needs. Profit is what makes business efficient.

    The reason government is not efficient is because profit is not systematized. Everyone in the public sector of course wants to profit but the profit is allocated not for efficiency and consumer satisfaction, it is allocated according to relationships in the organization and systemic failures are rewarded by increased budgets.

    The problem in the private sector is because it is barely free. Provider supply is artificially constricted. Pharmaceutical monopolies are protected. In state insurance cartels are protected. Well constrained subsidies are provided that drive up demand. Insane regulation that mandates all sorts of procedures be covered at the behest of every special interest group drives up demand. We have a tax policy that shifts resources to health care that must be spent or lost, driving up demand.

    What we have is a bleeding and scabbed husk of a market that can barely breath much less adapt.

  • Jerome Bigge||

    The problem with our health care system is that it costs too much for what we get. Americans pay about twice as much as the average for the rest of the developed world. Are we that more unhealthy than people in other countries? Or is it that because of the cost of American health care, we no longer can afford it?

  • ||

    Bullshit! Look, as a physician in Canada I always have to laugh when I see crap like this about cancer. And which country has the better outcomes? The problem with Canada is that for elective procedures there is a queue. However, when the system has to move, somehow it does. Yes, you can always point to one or two failures, but I can easily point to many more where the US system has failed the individual.

    Here's a truth for you: in both systems, care is rationed. In Canada, you might be in a queue. In the US, if you don't have good insurance, you're at the mercy of the system. I've worked in both systems, and neither is ideal. But I've never turned anyone away from my specialty practice in Canada, because I pretty much always get paid by the government run insurance scheme.

    And one more thing. It isn't "socialized medicine" in Canada. I am not on a salary. I bill fee-for-service. Therefore, the harder I work, the more I make. And I like to make, so the patients get seen.....

  • first||

    Nicole has enchanted us here at Hegre-Art with her sultry beauty. We are sure she will do the same for you.

    Her striking good looks and breast-length brunette hair are only the start. Nicole has a degree in psychology. She has a wisdom and an understanding of the human heart not often found in a woman of only 22 years. Perhaps that is why she has that haunting smile. A touch of mystery mingling with sensuality.

    But in front of the camera there are no secrets. Everything is laid bare.

    Those famous Ukrainian looks and figure come to perfection in Nicole. From her amazing long legs to her raven hair - and everywhere in between - she excels.

  • Dan||

    Medicare payments are counted as Consumer Spending! So money I would have saved is taken and given to a doctor/hospital and counted as a sale! What is the multiplier of this transfer payment? See if the gov wouldn't have taken that money from me I would save it and then it would be invested to grow productivity. Instead it is sent to Sick Care for the Obese. No Multiplier there!

  • Jerome Bigge||

    We would have done better by simply repealing prescription laws. Allow people to purchase medicine for their own personal use outside the USA if they wished. Check out Canadian prices sometimes. Less than what we pay. We have "free trade" in most everything but medicine. Ask why is this?

  • Jerome Bigge||

    We should ask why do Americans have to pay twice as much for their health care than do the people on the average in the rest of the developed world pay? In most of these countries they also live longer! So it isn't "inferior care".

  • ||

    Overall, a good article. The claim that physicians took a paycut only once under SGR is however, laughable. This may be true nominally, however I recently reviewed my payments for bronchoscopy with transbronchial lung biopsy as a pulmonologist. I started practice in 1992, and my first year billed approximately $714 per procedure of which Medicare paid approx $650. I just finished training to perform electromagnetic navigation bronchoscopy, a new technique to accomplish the same result (on much smaller lesions not previously amenable to biopsy with this technique) at the cost of an additional 20 to 30 minutes of my time and just checked the CPT code for the procedure which tells me CMS will pay me the princely sum of $102. This is an inflation adjusted 89% reduction. Meanwhile I just paid my plumber $99 to unstop my toilet (although he can do at least 2 toilets in the time required to do my 1 bronchoscopy) and the vet just made $213 (cash at the door- no cost to bill) by having his assistant stick her finger up my Black Lab's ass.

    Maybe this is why I spent 5 years before I could successfully recruit anyone to come and join in the fun as a physician associate. Maybe this is why I finally gave up private practice last year for a salaried position. Maybe this is why there is now a 2 month wait to be able to see me, given the fact I have little motivation to increase my work hours.

    There is a solution to this. However, it involves telling the truth that there is no free lunch and this is a degree of honesty of which the average politician is incapable. Therefore I suspect it will be solved with a combination of covert and overt rationing of care as we wait for the baby boomers to drop dead and all the while everything that was good about American Medicine withers and rots away from within.

  • ||

    The system is a mess and the devil is in the detail. The complexity of health administration and health provision makes cost-containment efforts fraught with risks of NOT getting the details right. We should all expect to spend a great deal of $$ for medical care in either taxes, health insurance or direct payments to providers. Everyone should have healthcare in the U.S. Unfortunately, I think the baby-boomer funded employer-based private health insurance system lulled people into feeling medical services should be free to the individual. Now that the baby boomers are on the edge of collecting, we are facing the deferred cost and no one feels obligated to pay the price for care. I'm not sure government is the right entity to solve these complex issues, and it seems to me that the CMS quagmire adds a cost burden onto the healthcare system. Unfortunately, it's too late - the government is already in this waste deep. Sad truth is American disregard for the connection between obesity/fast food/sitting and future medical expenses is going to break us. 2/3rds of Americans are overweight? Blindness, amputations, kidney disease, heart disease - all EXPENSIVE complications of (preventable) type 2 diabetes. Who's going to pay the chronic-health bills when people's bodies break down from obesity and sedentary lifestyles? I certainly don't think the cost should fall on the backs of providers. Our priorities are upside down - we should be introducing kindergartners to super-healthy school lunches instead of supporting the long-term business gooals fat-sugar-salt-MSG fast food industry. My daughter was served chocolate milk twice every day in kindergarten! Did someone convince city government that kids won't drink regular milk if that is all that's served? And, we wonder why we're headed for a health care train wreck in this country.

  • ||

    Of course when Day 1 of Medicare began, no one paid into the system as of yet, so of course, it was a new benefit (handout?) from Uncle Sam. Personal funding thru payroll deduction began immediately the following year. Now, look at the MILLIONS of people who paid into the system for over 4 DECADES (along with their employer)and then DIED before collecting a penny in benefits. Guess who kept all that money? That's right. Uncle Sam. 10,000 people a day are turning 65 which means new fresh funding money coming into the system via Part B premiums. This new group of "seniors" (boomers) are in much better helath than their predecessors and run tio the doctor alot less. They are fit, active and healthy but still pay their premiums.
    Focus on FRAUD. Focus on pork plans like Medicare Advantage. Consider raising the eligibility age to 66 or 67 & the system will be fine.

  • ||

    As several other people have commented, the central thesis of the article, that pricing mechanisms run by bureaucrats are inherently unable to control costs, and are less efficient to boot, is wrong. Maryland has a panel of bureaus which set prices for all hospital services in the state, and those costs have increased more slowly than the same costs in other states. I have not read about that program causing increased outpatient costs in the state. Japan has a panel of physicians which controls physician reimbursement. Each German state has global negotiations for hospital and physician budgets. Those non-market systems have been more effective at controlling costs than those in the US healthcare system in general. Many commenters have discussed shortfalls in non-US healthcare systems. A balanced review of quality metrics and measures of access does not show large advantages for the US system, despite its exceptionally high costs.

    Markets are not a panacea, by any means. Markets haven't worked in controlling Medicare Advantage costs- per member costs are higher than those in the Medicare fee-for-service program, despite the fact that Medicare Advantage uses privately-run insurers with managed care systems. The most dysfunctional part of the US health insurance market is the individual and small-group market, where prices are significantly higher and risk selection runs rampant. That sector of the market, I would argue, is also the most market-oriented, allowing individuals the most freedom select insurers and coverage levels, if they can meet rigorous qualification standards and can afford coverage. How many people would really like to see the US healthcare system look more like its individual market?

    It seems to me that the general population in America is confused by exactly what they want. Medicare,and to a lesser extent Medicaid, are popular (although you might not know it reading these comments). Yet there is a strong movement to limit the government's involvement in healthcare. I've done a fair amount of reading on the subject, and I can't find an example of a system that has less government control than America's. Even Singapore's system, I would argue, has greater government involvement than the American system (i.e. individual manate, guaranteed issue, government control of pricing through its sizable position as an insurer). I would like to see a real-world healthcare-specific example of what conservatives, libertarians, or free-market advocates would like to use as a template for health reform in the US.

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