My God, you are an idiot.

[Replaced_Texan]

Originally Posted by Hank Chinaski

any advice- i have an Uncle looking at cancer treatment. A surgeon wants to cut, but Unc wants to get a second opinion*, which makes sense and we will do that. But I wonder how one weighs the second opinion- are they typically given fairly, or are they tinted by the economy of "wanting to get the file?"

like if I advise someone how we should sue someone, then they go to Firm B, firm B will almost certainly say my plan is screwed up. any evidence of that popping up in med circles?

* my entire knowledge base is the sopranos where Junior's surgeon really wanted to cut him, but he got a second opinion from an oncologist, which was the better advice.

You'll get different points of view, but docs are pretty good about being more concerned about what they think is the best option for the patient than necessarily getting to do it themselves. You'll run into ego more than anything else.

[sebastian_dangerfield]

Originally Posted by Replaced_Texan

Nah. Just very much wanted in smaller communities. My cousin-in-law has a very, very sweet deal in Longview, Texas. My cousin, his wife, doing straight up internal medicine in a hospice setting, makes a fraction of what he does. They graduated one and three in their medical school class and excelled at their respecitve residencies in one of the top teaching hospitals in the country. Theoretically, they should be on par with one another, financially.

I think that some physicians are grossly over-paid and some are grossly under-paid. Depends on the specialty and how reimbursement works in their areas or specialties. Dermatologists rake in the cash when pediatricians can barely make enough to cover overhead. My anestheisologist made more than my surgeon when I had my gallbladder taken out a few years ago.

We do a horrible job of aligning reimbursement with effectiveness. Look at stents, for example. No evidence whatsoever that they do any better than drugs. But cardiologists get a heck of a lot more money if they hang out in the cath lab shoving metal up arteries than if they hang out in a clinic writing prescriptions and talking to their patients.

Medical school education is really, really expensive. But, so are a lot of other schools. You don't hear people crying over the people who spent $40k on cooking school and then end up in $18k a year jobs afterwards. There are thousands of newly minted lawyers out there in mortgage sized debt who can't find jobs at all, much less jobs that can put a dent in the loans.

I'd love to cut down on the cost of education borne by the student. But my legislature--and the legislatures of a lot of other states--aren't particularly interested in that sort of thing.

It's fitting two grossly overpriced services - education and healthcare - should be discussed in tandem. Aside from the way one's cost impacts the other's, they share a common driver found in every inefficient, cost and debt-ballooning product/service delivery industry: Third Party Payment Structures.

Third party payment structures don't work. And they never will in any consumer setting.* The only way to curb costs, over-use and poor use is to make the purchaser feel the pinch at the point of payment. As long as people can think, "Maybe insurance will cover this test," or "I'll find some way to pay off this $100k History degree later," people will purchase that which they cannot afford. It is proven millions of times a day, every day, and yet our solution is to tweak the third party payment structures at the margins while never addressing the root problem. It's classic "Doing the same thing, expecting a different result."

And I know the response I'll hear... "We can't go and remove govt guarantees on student loans, or drastically overhaul health insurance to force people to pay more directly. It's unrealistic... People are conditioned to what we have - what they expect. We can't radically change it." This is what some author a few years ago called the tyranny of bad ideas. That something bad is ubiquitous, that it might be woven into our collective understanding of how society and government operates, doesn't mean that it must persist forever. Or can persist forever. If it violates math and renders us uncompetitive, it's going to be radically changed one way or another. The only question is whether we address it pre-emptively, or wait for crisis.**

*Outside credit cards, factoring models for which only work because the creditor controls the cash flow and can directly hammer the borrower for payment... and makes money on high enough across-the-board interest to offset losses.

**I give Obama credit for at least trying to fix health care. Sadly, his approach included an expansion of third party payment structures, which ultimately makes the problem more acute. Too much policy think, not enough appreciation of how a market, and the brain of the common consumer, operate.

[Adder]

Originally Posted by sebastian_dangerfield

*Outside credit cards, factoring models for which only work because the creditor controls the cash flow and can directly hammer the borrower for payment... and makes money on high enough across-the-board interest to offset losses.

Credit cards aren't third-party payer situations. There isn't anyone guaranteeing your credit card debt, and the lenders have to weigh risks accordingly.

ETA: Btw, students loans are an interesting variation as the third party guarantee only explains some of the $100k in loans to the history major. Apparently the private lender who is providing the rest is sufficiently comfortable with the interest he's getting and the student's projected ability to pay. So I guess I'm skeptical that you've pinpointed the right source of the problem for escalating education costs. I think it has more to do with supply and demand, and having "artificially" constrained supply, the institutions' ability to extract higher payments thanks to the availability of financing.

Too much policy think, not enough appreciation of how a market, and the brain of the common consumer, operate.

I don't think that's accurate. He just isn't interested in a world in which we just write off people who can't afford to pay for their health care.

Obviously if one is freed of the constraint of wanting to provide health care for all (or all old people), it's pretty easy to control the cost of health care to taxpayers.

[sebastian_dangerfield]

Originally Posted by Adder

Credit cards aren't third-party payer situations. There isn't anyone guaranteeing your credit card debt, and the lenders have to weigh risks accordingly.

ETA: Btw, students loans are an interesting variation as the third party guarantee only explains some of the $100k in loans to the history major. Apparently the private lender who is providing the rest is sufficiently comfortable with the interest he's getting and the student's projected ability to pay. So I guess I'm skeptical that you've pinpointed the right source of the problem for escalating education costs. I think it has more to do with supply and demand, and having "artificially" constrained supply, the institutions' ability to extract higher payments thanks to the availability of financing.

I don't think that's accurate. He just isn't interested in a world in which we just write off people who can't afford to pay for their health care.

Obviously if one is freed of the constraint of wanting to provide health care for all (or all old people), it's pretty easy to control the cost of health care to taxpayers.

The relevant psychological factors at work in use of a health insurance card, credit card, or student loan, are near identical. Divorce a person from the act of feeling money leave his wallet, or writing a check for something, and he will spend more.

I'm not advocating writing anyone off anything. I'm advocating a shift, slowly, incrementally, toward more of a direct purchaser model. Prices will drop as the revenue stream from third party payments decreases (supply, demand, etc.). It's not in debate whether a third party payment structure drives prices upward. It's just a question of how much. We can reverse the trend toward an exclusively govt/insurer-run HC system and in doing so, reduce costs.*

There's no constrained supply in education. A huge percentage of the $600bil in non-performing educational debt is tied to for profit institutions that let anyone in the door and charge a ridiculous tuition, often above that charged by an actually accredited, and 10X better state school.

*The loudest argument against trying to do this is that the common person cannot manage his finances, or his health care. Essentially, it is "We have to have a third party take care of a large part of this country because these people will not be able to, or won't care enough to, take care of themselves." There's a lot of merit to that. I think we'll always need Medicare to take care of those who simply don't have resources. But as to the second group - those who are able but would rather spend the money elsewhere, or not bother being responsible for themselves - I'm having a hard time justifying why they deserve anything. Just about the same kind of hard time I have justifying why bankers whose firms should have collapsed in a true free market should receive bonuses on par with what they received in 2007. These "free riders," it seems to me, should be left to fend for themselves. (I know... I know... "How do we separate the merely irresponsible from the truly needy?" Vexing.)

[Tyrone Slothrop]

Originally Posted by Hank Chinaski

I was just messing with that one (though your logic= "Nixon put a man on the moon, Kennedy and Johnson couldn't") but the wiki-leak thing is scary, and I wonder why it hasn't been reported (not as an anti-obama thing as an anti-guy who leaked it thing)

Maybe I haven't been keeping up with the Twitter lately, but I have no idea what you're talking about. What are you talking about?

[Adder]

Originally Posted by sebastian_dangerfield

The relevant psychological factors at work in use of a health insurance card, credit card, or student loan, are near identical.

The difference is that you have to pay the credit card or student loan eventually, which means at some point there is a reversal of the psychological effect from which the consumer can learn.

I'm not advocating writing anyone off anything.

I know you aren't. And I actually agree with you that people paying for things out of pocket would reduce consumption and therefore reduce total health care costs.

The problems are that some people think reducing consumption is bad (I want my antibiotics for this cold, dammit!) and what to do with those who can't afford to pay out of pocket (i.e., anyone elderly).

Personally I think the second problem is sufficiently large that a third-party-payer-free health system is a pipe dream, so we have to move on to how to make the system work with third party payer involvement.

There's no constrained supply in education.

That's just laughable. Between licensing, accreditation, and reputational barriers to entry, there is significantly constrained supply. I find it hard to believe that you want to argue otherwise.

A huge percentage of the $600bil in non-performing educational debt is tied to for profit institutions that let anyone in the door and charge a ridiculous tuition, often above that charged by an actually accredited, and 10X better state school.

Right. Because of constrained supply by the real schools.

GW doesn't get $50k a year (or whatever) because there are abundant alternatives out there.

I think we'll always need Medicare to take care of those who simply don't have resources.

The biggest issue is that almost anyone old is among those who simply don't have the resources.

[Cletus Miller]

Originally Posted by Adder

The difference is that you have to pay the credit card or student loan eventually, which means at some point there is a reversal of the psychological effect from which the consumer can learn.

You have to pay one eventually; the other is just a phone call to your local bankruptcy mill away from disappearing. It's a *huge* difference.

[Cletus Miller]

Say it isn't so!!

[Greedy,Greedy,Greedy]

Originally Posted by Replaced_Texan

Interventionalist radiologists. Guys who read images don't make nearly as much as those who aim and fix.

We've still got some of those in the 200K realm; most of the interventionalist stuff is the land of big turf battles around here, and radiologists don't win a lot of turf battles.

[Adder]

Interesting duo of charts, showing how we are on the low end of number of docs per capita (in the developed world) and, of course, high end of total healthcare expenditures.

[Adder]

Originally Posted by Hank Chinaski

oh. that's why I was asking before. I don't simply believe blog stories.

This one seems to suggest that the Jan character (quoted in the bit of al Libi's report you gave us) was the key courier, but says that al Libi gave a false name. I'm still not clear on whether Jan is the false name (and thus the wikileaked file includes the false name).

It also goes on to argue that torturing KSM and al Libi actually hampered the hunt for OBL.

[Tyrone Slothrop]

This is the most interesting thing I've read about politics in a while, and it certainly gives me new respect for Sarah Palin. It also tends to make you think better of McCain's choice of her.

[Tyrone Slothrop]

Originally Posted by sebastian_dangerfield

It's fitting two grossly overpriced services - education and healthcare - should be discussed in tandem. Aside from the way one's cost impacts the other's, they share a common driver found in every inefficient, cost and debt-ballooning product/service delivery industry: Third Party Payment Structures.

It seems to me that the bigger problem the two markets share is that it's really difficult to assess outputs, and this makes it much harder to create the right incentives to make them work more efficiently.

[Ty@50]

Originally Posted by Tyrone Slothrop

This is the most interesting thing I've read about politics in a while, and it certainly gives me new respect for Sarah Palin. It also tends to make you think better of McCain's choice of her.

this is when I first realized I'd been wrong about the 2008 election, and of course I still felt the ass about the Iraq surge. We're getting really close to the time I began turning.

[Replaced_Texan]

Originally Posted by sebastian_dangerfield

The relevant psychological factors at work in use of a health insurance card, credit card, or student loan, are near identical. Divorce a person from the act of feeling money leave his wallet, or writing a check for something, and he will spend more.

I'm not advocating writing anyone off anything. I'm advocating a shift, slowly, incrementally, toward more of a direct purchaser model. Prices will drop as the revenue stream from third party payments decreases (supply, demand, etc.). It's not in debate whether a third party payment structure drives prices upward. It's just a question of how much. We can reverse the trend toward an exclusively govt/insurer-run HC system and in doing so, reduce costs.*

There's no constrained supply in education. A huge percentage of the $600bil in non-performing educational debt is tied to for profit institutions that let anyone in the door and charge a ridiculous tuition, often above that charged by an actually accredited, and 10X better state school.

*The loudest argument against trying to do this is that the common person cannot manage his finances, or his health care. Essentially, it is "We have to have a third party take care of a large part of this country because these people will not be able to, or won't care enough to, take care of themselves." There's a lot of merit to that. I think we'll always need Medicare to take care of those who simply don't have resources. But as to the second group - those who are able but would rather spend the money elsewhere, or not bother being responsible for themselves - I'm having a hard time justifying why they deserve anything. Just about the same kind of hard time I have justifying why bankers whose firms should have collapsed in a true free market should receive bonuses on par with what they received in 2007. These "free riders," it seems to me, should be left to fend for themselves. (I know... I know... "How do we separate the merely irresponsible from the truly needy?" Vexing.)

I dunno. I have health insurance, my fiance doesn't. (He will when we get married next year, but that's not particularly helpful right now.) Both of our necks got jacked pretty badly in the crash last week*, and right now, we need the same exact care. It's not a consumer choice that we're left with. If we don't get our necks checked out and treated, it probably would get worse and more expensive and/or debilitating.**

I don't really see how it's possible to shop around for the "best value" in physical medicine. There's no website he can check to see where the prices are the best. There's not even a physician out there that posts her rates. When I made the appointment for us, the clinic (chosen because it's one of the entities I work for) said that his cash outlay would be anywhere between $78 and $350, depending on what happens. How on earth can he make a informed choice as a consumer when until he's seen and treated, no one has a clue how much he'll be charged? And this is just the initial assessment. If he needs PT or radiology or whatever, it's not like he has the knowledge or experience to determine what the cost effective, best for the consumer choice is.


*Hopefully Farmer's, the other guy's insurance,will pick all of this up, but the initial charge will be to my fiance, and we know that the insurance company will go through all bills with a fine toothed comb.

**His sometimes painful sciatica and hernia remain untreated, because he's very aware of the costs of taking care of those two things. His asthma is sort of treated, but only because my dad is a lung doctor and keeps his albuterol prescription filled and will hand over the occasional samples of Symbicort and Singulair that happen to be dropped off by drug reps. Albuterol, for those wondering, costs $47.90 more or less every three weeks if you do not have health insurance.