Re: Preventative care helps
 

But Bernie would have won!

Re: Preventative care helps
 

Have a cancer doc in the family.

"Aside from smoking, sun exposure, and to a small extent, diet, there are very few things you can control. It's all genes."

Along those lines... https://www.nytimes.com/2014/02/12/h...ammograms.html

Re: I used to be disgusted, and now I try to be amused.
 

I don't know why you think there will be all this negotiating taking place. For rote preventative care, units will have prices. People aren't going to walk into the doc and say, "How much for a physical? $100? No way. I'll give you $75." It's not going to be a flea market.

Prices will be more transparent, and with that there will be enhancement of competition among providers. This naturally benefits consumers.

Why do you prefer the opaque pricing system we currently use? If you're truly concerned about informational asymmetries, how can you argue against publishing prices to consumers?

Re: I used to be disgusted, and now I try to be amused.
 

Right now we need to focus on winning a bunch of seats in Congress and at least hold our own in the Senate in two years.

And we need some Senate Republicans to work together on some key issues.

As to the next Presidential, there are many maps available. Let's not get ahead of ourselves four years out.

Re: I used to be disgusted, and now I try to be amused.
 

I like her crusade to unwind the 2005 bankruptcy bill, but otherwise, Warren's a hot mess. http://www.vanityfair.com/news/2017/...020-poll-trump

Re: I used to be disgusted, and now I try to be amused.
 

You don't even need to get more people out, just get them thinking straight.

Re: I used to be disgusted, and now I try to be amused.
 

I don't disagree.

There are many other things Dems could do to advance their cause, such as putting forward a decent candidate. Or engaging in less identity politics that turns off the people in flyover states. But a number of people who self-identify as The Resistance have decided that giving the Rs a greater majority in the Senate by taking out Manchin or McCaskill and running a far lefty is the way to go.

And you know what, I kind of liked 2003 Elizabeth Warren. I found it interesting that she was so against DeVos, when 2003 Elizabeth Warren was such a proponent of school choice, given how she identified rising property values in good school districts as such a major cause of financial instability for families in The Two Income Trap. But that was before Senator Warren took a bunch of money from teachers unions.

Re: I used to be disgusted, and now I try to be amused.
 

I have my own issues with Liz, but she is wicked smaht, adds a useful voice to every debate, and has been astonishingly effective on constituent services. But I like her in the Senate, and I don't think she'd be a great executive.

I'm actually very fond of Jon Tester. I think he could surprise a lot of people in a national race, including a lot of progressives. He's worth a close look, assuming he gets past his 2018 race. I'm also still fond of Kirsten Gillibrand.

You do realize that DeVos is just flat out incompetent, don't you? It's not just an ideological difference. Watching her testimony was painful.

Re: Preventative care helps
 

But they don't really care, and the people who don't like it really don't like it.

Re: I used to be disgusted, and now I try to be amused.
 

This is one of those times when I realize I spent too much time talking to economists.

Sure there will be unit prices. Those unit prices exist now, and are the subject of bargaining between your provider and your insurer, which has a strong interest in forcing them down. If you have to pay for your preventative care yourself, you can't rely on the insurer for that function. You're going to shop around. How often you shop around will depend on your tolerance for collecting unit price information from different providers for the different things and assessing the likelihood that you will need to purchase the different units, and also on your switching costs.

If you think that world is going to produce lower prices, you are totally nuts. No one wants to do that stuff, which is why they are happy to pay an insurer to do it for them. The insurer can do it for a bunch of people at once, taking advantage of economies of scale and scope, and is more sophisticated about this stuff than you are, avoiding information asymmetries.

Prices are completely transparent right now to the insurer, which is the entity with which the provider is negotiating prices. There is plenty of competition between providers, and insurers.

It is true that if you see zero marginal cost to doing a procedure, the cost to your insurer is no disincentive, and you may overconsume. However, your insurer has thought of that, and is very interested in keeping you from obtaining healthcare you don't need. As others pointed out, this is not so much of a problem with preventative care, which is why it's a little odd for you to focus here. Preventative care is not that expensive, and it has the nice effect of reducing costs down the road. So in fact there is a danger in preventing people from buying insurance to cover it, since they may then under consume.

It doesn't benefit consumers to force them to participate in a market they don't want to be in. Would you rather buy a pass that lets you ride the bus for a month, or would you rather negotiate whether and how much you'll pay each time you board? If you take the bus much at all, and I'm sure you don't, you'll know it's the former.

Re: I used to be disgusted, and now I try to be amused.
 

Yeah, that's what I mean. Stepping back on civil rights isn't going to be a winning strategy. Even if there are any white guy votes to by acquired that way (doubtful, especially when your opponent is promising to actively harm the people they dislike), it comes with a side effect of progressive and voters of color staying home.

And, frankly, I'd rather lose than stop being the party that stands up for marginalized people.

Honestly, I've never liked Elizabether Warren. I mean, she's good on policy for the most part, but there's something affected-third-grade-teacher about her persona that I've always found off-putting.

That's probably grounded in mysogny.

Or maybe she figured out that DeVos-style school choice doesn't work and that the interests of rich suburbanites shouldn't really be driving policy decisions.

Re: I used to be disgusted, and now I try to be amused.
 

You don't think about economics, mental health, or overconsumption as much as Sebby does.

Re: Preventative care helps
 

Yeah, we got to get more people caring.

It matters.

Re: I used to be disgusted, and now I try to be amused.
 

1. People have never been offered an option to the TPA system. It's been the rule for as long as anyone can recall. Hence, the assumption people prefer it doesn't hold.

2. That people are joining concierge practices indicates people do not resoundingly prefer a TPA structure. They prefer direct purchase.

3. Insurance is a far bigger headache to consumers than direct price shopping.

4. Here's the important point...

Providers inflate unit prices enormously to offset the discount insurers demand. This inflates costs across the board, including costs for catastrophic and chronic care.

Pull the insurer out of one form of care, preventative, and you'll remove the inflated price charged by providers in that area. Where the provider charged $1000 for something in order to get $150 from an insurer, now it'll only be able to charge the direct consumer something along a lines of $150, the true value of the service. When that price falls, so to will the prices charged for catastrophic and chronic care, as they inform each other.

You see where I'm going. Pull the inflating mechanism out of any single area of care (preventative, chronic, or catastrophic), and it deflates or at least flatlines or pares the level on increase in the prices in the others. I only chose to apply it to preventative care first because that's the only care a consumer could afford to purchase directly.

Re: I used to be disgusted, and now I try to be amused.
 

You don't seem to realize that your 1. and 2. contradict each other. Also, no one requires TPAs to cover preventative care in the way that they do. If it really made things cheaper in a way that was valuable to consumers, why isn't it out there in a bigger way?

Not sure what this means or what your point is. You're suggesting the worst of both worlds -- consumer still need insurance for most health care (in spending terms), but are compelled to buy direct for preventative care.

I think the fact that you think this is true is the root of the problem. Providers have "prices" that they give to consumers, and charge people who turn out to be uninsured, and then they have the real prices that they negotiate with insurers. The "prices" are not usually the real prices. Providers don't charge $1000 to get $150 from an insurer. They know they are going to get $150 from the insurer, and they will get that $150 regardless of whether they tell you that the price is $1,000,000,000, $1000, or $150. The only people who pay $1000 are the people who have no coverage, and they get screwed because they have no bargaining power and huge information asymmetries. What you don't seem to understand is that price is a function of both supply and demand, and that buying medical care through an insurer gives you, a consumer, better bargaining power. That $1000 "price" is a reflection of what happens when the consumer doesn't have it. You think that taking consumers' bargaining leverage away and forcing them to negotiate individual with providers is going to leave them better off. For some, perhaps, which is why you have concierge services. But let's assume that people are rational, because you haven't identified any way in which people are predictably acting irrational here -- for all the people who *aren't* using concierge services right now, isn't that a pretty strong indication that they don't want to, and would be worse off if you took their first choice away?

You haven't identified an "inflating mechanism".

Re: I used to be disgusted, and now I try to be amused.
 

Of course, if one wants a model for obtaining less expensive health care, you could look and see what models that are actually out there in practice provide cheaper coverage right now.

Re: I used to be disgusted, and now I try to be amused.
 

If this is meant as a joke, okay, but if you are serious, you are crippled (or I suppose you might say "male raised challenged").

Re: What do you have against misogynists, anyway?
 

I think he meant it as a joke, but like all good jokes, it's funny because it has such a strong element of truth to it.

Offer me alternatives, offer me solutions - but I decline.
 

I don't know anything about the macro health care issue (other than as a somewhat reasonably informed HC consumer - hence my comments to Hank about how my personal HC plans seemed to constantly reduce coverage/increase co-pays long before Barry was even a state senator), so RT has my proxy on the big picture. That said, I think you, Hank, and Sebby each have knowledge that I don't because of your respective experiences.

Anyway, I really have nothing to add. It's just that I've been working on a song parody to an REM song, and your response to Sebby brought the re line to the front of my brain.

Carry on.

Re: I used to be disgusted, and now I try to be amused.
 

Yep, they do it the easy way. They get rid of the expensive stuff.

Want an MRI? Sure, the next appointment is June 2018.

You're 68 and need chemo? Sorry, but here's a pain pill and a hospital bed. Call us when it's "time."

Re: I used to be disgusted, and now I try to be amused.
 

Concierge has just started to emerge as an alternative.

It is out there in a big way. A TPA is the way health care is delivered for almost everyone. That's my whole argument.

You have it backwards. If preventative costs were on the consumer, which would cause them to fall, you'd see a corresponding drop in catastrophic and chronic care costs. It's the best of both worlds. Insurance costs drop, and preventative care costs drop.

Incorrect. That's exactly why they do it. Why else would they? Under these circumstances, there is no business purpose achieved by an inflated price except to create bargaining power with insurers. Additionally, having managed HC debt portfolios, I can tell you providers have admitted this is exactly why they inflate the price.

Incorrect. It's bargaining leverage.

They pay very little, if anything. No provider is inflating the price to enhance their ability to force a little more blood from a stone.

Re: I used to be disgusted, and now I try to be amused.
 

That's what an economist would say. That's not what's actually happening.

Yes. Market forces would compel pricing at affordable rates.

No. It's an indication that people go with the flow, and alternatives like concierge are slow to emerge. "Tyranny of tired ideas" is one way I've heard of describing the situation.

Yes I did -- the providers' price inflation to offset bulk discounts demanded by insurers.

Re: I used to be disgusted, and now I try to be amused.
 

In the world the rest of us live in, bigger, more sophisticated purchasers have more leverage to get a better price. If you are Avis, you can buy sedans for a better price than if you are Sebby.

In your world, a car dealer gets an RFP for a fleet purchase from Avis, and has a brilliant idea -- it just tells Avis that its prices are higher, and voila! Profits!

Re: I used to be disgusted, and now I try to be amused.
 

I trust you've gotten yourself a concierge service and have some private arrangement for when the serious stuff hits.

Good luck to you.

Re: I used to be disgusted, and now I try to be amused.
 

I fear going to a world where we have to bid on medical services, because we have half of Ontario over here trying to get stuff done they can't get done under single payer.

Re: I used to be disgusted, and now I try to be amused.
 

Um... these aren't mutually exclusive scenarios. In fact, my point has been that the first in part causes the second.

I'd rather not tempt the "appeal to authority" logical fallacy, but as you raise the "rest of the world agrees with me" angle, I, uh, do live in a home with a HC provider/practice owner. I'm not just the hair club president, but also a member, so if I'm trying to refrain from going there, repay the courtesy.

Yes, I fully realize I already went there a bit when I discussed working with HC debt. That was wrong of me, and for it, I apologize.

Re: I used to be disgusted, and now I try to be amused.
 

Well, maybe they can be customers for Sebby's concierge services.

Most of the countries with single payor systems have a modest for-pay health care system on the side. Interestingly, people usually choose to buy insurance to pay for it. I don't know how Canadians coming over are doing things - are they paying full boat, undiscounted prices for MRIs or are they buying some form of insurance that lets them use providers here in the south?

Re: I used to be disgusted, and now I try to be amused.
 

P. 31-35: https://www.law.uh.edu/hjhlp/volumes/Vol_14/Brown.pdf

Also happens at independent practice level.

Re: I used to be disgusted, and now I try to be amused.
 

My point is that the second scenario is absurd.

Re: I used to be disgusted, and now I try to be amused.
 

I like the irony of your citing a medical authority from Houston here.

Re: I used to be disgusted, and now I try to be amused.
 

I wish I could take credit, but I'm not facile enough with the Google to have done that intentionally.

Re: I used to be disgusted, and now I try to be amused.
 

Except it's not, and saying it's absurd is incorrect.

Don't dissemble. I'm not trying to "win," and this is not a zero sum game. It's a discussion, and I just wanted to expose an overlooked perverse incentive that warps prices.

Re: I used to be disgusted, and now I try to be amused.
 

It's not a joke.

Re: I used to be disgusted, and now I try to be amused.
 

Every once in awhile I have the pleasure of sitting down with our health care group, which among other things represents physician groups and practices, to whom the whole "antitrust" thing is a bit foreign. The one message that's completely clear from those conversations, however, is how the docs are getting fat on how much they get to charge third party payers :rolleyes:

Re: national brotherhood week
 

Everyone thinks everyone else is overpaid while they are overworked.

Docs and hospitals, blame drug companies and device manufacturers, who blame third party payors, who blame hospitals and doctors, who then blame each other. And everyone blames the lawyers.

Re: national brotherhood week
 

Every one of those groups except the lawyers is overpaid in our system. ;)

But more seriously, sure, docs inflate the reported headline price but that doesn't imply that insurers aren't ultimately getting the lowest available price.

Re: I used to be disgusted, and now I try to be amused.
 

It is absurd, and your ability to use the Google to find an obscure article by an obscure law professor in an obscure journal doesn't change that. In reality, Avis gets better prices when it buys cars than you do.

All else equal, a seller of goods may be able to get some relative benefit from anchoring with a high initial price. But all else is not equal, and the other benefits that insurers have in negotiating with providers are considerable. Moreover -- and this seems to be another key point that you have no answer to -- if anchoring gives an advantage in negotiations with insurers, it surely gives no less of an advantage in negotiations with individual consumers.

You haven't identified a perverse incentive. You've discovered that health-care providers want to charge as much as they can for their services, just like any other for-profit enterprise.

Re: I used to be disgusted, and now I try to be amused.
 

I could offer dozens of articles showing how the TPA system warps prices. Did you see the footnotes in the paper? They're more than half the page on many pages.

I said the TPA system warps prices. I supported my contention. I suggested that a system in which that warping was removed could lower costs across the board. You have responded to that by simply repeating, "Insurance gets the consumer a better price on preventative care!" You still have not addressed the argument that removal of the TPA system for preventative care could provide savings on ALL forms of care, in aggregate, which outweigh the preventative care savings from the TPA's intervention.

Re: I used to be disgusted, and now I try to be amused.
 

I did not take it as a joke. If you dislike a female politician because she's too schoolmarmy for you, it is based in misogyny. It's good of you to at least recognize that.

I have thought A LOT about our brand of misogyny over the last year. And I read (listened to the audiobook of) A Brief History of Misogyny by Jack Holland, which offers an interesting historical perspective, but alas ends before our current era and was more optimistic about present day when it ended in the early 2000's (the author died in 2004 and this book was published posthumously) than it might be if published today.

Re: I used to be disgusted, and now I try to be amused.
 

You understand that the disagreement is about this part, right?