Health Care Law Massacred in Supreme Court

[KenC]

The other ~half of the group are 19-34yos that make 25-75k.
An issue that's just as important, but much more difficult to objectively analyze is the population of underinsured individuals. Those who technically have insurance, but with such minimal coverage that it's essentially useless for anything other than injuries and dismemberment.
In any case, you're correct that insuring everybody isn't going to drastically lower the cost of care. It will some, but not a whole lot. Overall, I think it's safe to say that universal coverage would contribute to overall health improvements. It's difficult to quantify what impact that may have economically or socially, but isn't improving the heath of our citizens the ultimate goal of the entire industry?

Insurance reform isn't our biggest issue, however. Health care delivery reform is what's really needed.
There were/are a few good nuggets within the Affordable Care Act. Specific compensation for physicians to assist with end of life planning is fantastic. It's a very difficult subject for many, and although important, patients often don't like to think about their eventual demise. This can be a cumbersome process for many physicians.

Our health care here will always cost more than it does in the rest of the world. Partly because of the fact that we finance new technology. This is a double edged sword. It's good because we sometimes get some great new stuff, but if you've ever had experience with the medical device world, you know how market driven (as opposed to clinical efficacy driven) it is. A lot of times we pay for expensive new devices that aren't really any more effective but are 10x more expensive. Sometimes we even get detrimental products, such as the metal on metal hip implants. Devices only have to prove to the FDA that they're not harmful. They don't do any sort of efficacy or "value" assessments on them. Of course each company peddles their new product like it's the greatest invention since the coronary stent. A lot of European countries are slower to adopt new technologies, but most of them also have an agency that evaluates each item to make sure it is actually worth paying the $$$ for it.

I'm digressing a bit here. I'm a little tired of typing but I could go on for hours about care delivery.

[Kershaw]

please do. maybe you'll change a few minds about this.

[rwh11385]

An issue that's just as important, but much more difficult to objectively analyze is the population of underinsured individuals. Those who technically have insurance, but with such minimal coverage that it's essentially useless for anything other than injuries and dismemberment.

But would the guvment add another smaller fee for those who who are insured but not insured good enuf?

You'll never "incentive" people to pay for uber nice care if they don't see the point. I was always on high deductible with an HSA to cover the rare sickness or new glasses, and be covered for a big emergency... but not dropping a lot of coin for care I wouldn't need. Even now with a basic individual one, I've paid thousands for one tetanus shot?

In any case, you're correct that insuring everybody isn't going to drastically lower the cost of care. It will some, but not a whole lot. Overall, I think it's safe to say that universal coverage would contribute to overall health improvements. It's difficult to quantify what impact that may have economically or socially, but isn't improving the heath of our citizens the ultimate goal of the entire industry?

[And the paragraph about healthcare technology]

Um, you'd think. But that's not necessarily true for all companies. That link I posted at the beginning of the thread to respond to nrube's idea that competition is evil and that all healthcare companies would do whatever possible to make a buck... that NPO care far out-performs for-profit. Maybe if people used health care services which (profit or not) worried more about service and efficacy and efficiency than tracking margins, then maybe care would improve.

A LOT of corporations I've been at or dealt with spent twice as much time tracking budgets and margin, rather than project results and end product. It's only when the product / customer / etc. is put as #1 priority does the company succeed. Plenty of companies had to "fight the bean counters" at one time or another but many US ones seem to have lost, or did lose in the past few decades, although more are re-focusing thankfully.

Companies spend truckloads of money to make marginal gains for a great increase in price, rather than: a) breakthrough novel strategy that might give leaps and bounds improvement or b) simple and cost-effective tools for communities most in need, like developing world. Although quite poor, that market is HUGE and could not only provide market opportunity but improve the bottom line for US care

Insurance reform isn't our biggest issue, however. Health care delivery reform is what's really needed.

I don't think forcing people to do something that they should do is necessarily the answer, even if marginal people might fall in line. I'd like all kids to do Street Survival to help save their lives, but don't think we should have regulations to make them.

And resolving the cost problem would help with the affordability of care issue, rather than push everyone to get covered before fixing the cost issue. It won't magically get as cheap for some as in other countries (fat, diabetic, stressed out) but we could make preventive, regular care and health maintenance programs cheap enough to make economical sense to anyone with half a brain. (unsure on the percentage of the US population that includes)

[KenC]

When I say "care delivery," I'm referring to care providers (physicians, PAs, NPs, etc) actually administering care. It's frightening how varying and inconsistent treatments are. Evidence-based medicine has to play a larger role in the future of health care. It's tough to implement universally when half of the physicians in the US operate in small private (isolated) clinics.
85% of our health care expenditures are consumed by only 15% of the patients. Focus needs to be centered on providing the correct care in outpatient settings to prevent unnecessary expensive hospital admissions.

When I wrote of for profit markets I was speaking of the medical device sector exclusively. NP care plans/HMOs have always out performed their for profit competitors. A lot of them are academic health centers.

[KenC]

Forgot the insurance part.

You and I are young enough that an all-inclusive plan with ridiculous premiums doesn't make any sense. I'm in the same boat as you with utilization. Other than my med school physical, I haven't had more than a flu shot for the last five years.
It's the middle aged population with shitty coverage that worries me. They often forgo expensive routine physicals and any other health maintenance. The number of 40-60yos having strokes is increasing mainly because they're not aware of their hypertension. Diuretics that are pennies per day can prevent $X0,000 hospital stays/procedures.

[rwh11385]

When I say "care delivery," I'm referring to care providers (physicians, PAs, NPs, etc) actually administering care. It's frightening how varying and inconsistent treatments are. Evidence-based medicine has to play a larger role in the future of health care. It's tough to implement universally when half of the physicians in the US operate in small private (isolated) clinics.
85% of our health care expenditures are consumed by only 15% of the patients. Focus needs to be centered on providing the correct care in outpatient settings to prevent unnecessary expensive hospital admissions.

When I wrote of for profit markets I was speaking of the medical device sector exclusively. NP care plans/HMOs have always out performed their for profit competitors. A lot of them are academic health centers.

That makes logical sense, but would Obamacare actually do anything for that? Or instead of tackling the real issues, it throws up a red herring of coverage? [After which, the liberals declare victory and stop caring about underlying concerns rather than blanket solution]

Yeah, there's multiple industries being discussed as one, but how many companies in each direct care, administration, and devices actually being truly innovative or novel rather than simply "managing"? Are any health networks of physicians working to align care delivery? Are plans working to streamline non-valued work (and employees) to maximize patient health and care for their premiums taken? Are device and technology companies looking at any high risk ideas rather than simply polishing the same thing year after year?

[Health care plans] You mentioned required % of premium going to direct care before, but does the industry track and publish that?

[KenC]

And resolving the cost problem would help with the affordability of care issue, rather than push everyone to get covered before fixing the cost issue. It won't magically get as cheap for some as in other countries (fat, diabetic, stressed out) but we could make preventive, regular care and health maintenance programs cheap enough to make economical sense to anyone with half a brain. (unsure on the percentage of the US population that includes)

That's the only thing that's going to save it. Insuring everybody isn't going to miraculously drive costs down.
Providing more coordinated outpatient care while using Best Practices (evidence based) care as a guideline will prevent unnecessary hospitalizations. If our higher cocorrelate directly correlated with positive outcomes, we wouldn't be having this conversation. It's all about health maintenance and wellness promotion as you mentioned.

Covering our entire country has a non-monetary/economic aspect to it though. We should strive to provide the best possible care to all of our citizens in hope of achieving a healthier, happier, and more productive populace.

[rwh11385]

Forgot the insurance part.

You and I are young enough that an all-inclusive plan with ridiculous premiums doesn't make any sense. I'm in the same boat as you with utilization. Other than my med school physical, I haven't had more than a flu shot for the last five years.
It's the middle aged population with shitty coverage that worries me. They often forgo expensive routine physicals and any other health maintenance. The number of 40-60yos having strokes is increasing mainly because they're not aware of their hypertension. Diuretics that are pennies per day can prevent $X0,000 hospital stays/procedures.

That's the only thing that's going to save it. Insuring everybody isn't going to miraculously drive costs down.
Providing more coordinated outpatient care while using Best Practices (evidence based) care as a guideline will prevent unnecessary hospitalizations. If our higher cocorrelate directly correlated with positive outcomes, we wouldn't be having this conversation. It's all about health maintenance and wellness promotion as you mentioned.

Covering our entire country has a non-monetary/economic aspect to it though. We should strive to provide the best possible care to all of our citizens in hope of achieving a healthier, happier, and more productive populace.

Yes. There's some affordability of that proactive care to bring down to "duh, of course I'll go do that" levels, but understanding the economics of catching a problem before it blows up is huge, as is a cultural aspect. [Breast cancer screening communication and acceptance of 'just what you ought to do'] Tracking overall patient cost with or without regular checks will be key, as well will the increase in wellness programs. An increasing number of companies have some kind of contest or financial incentive to remain in good shape, and if they display positive results in employee moral, work quality, loyalty, or also lower company health care program costs, hopefully they will increase further.

As much as we can have NFL players encouraging kids to Play 60 or Fallon challenging Mrs. Obama in a potato-sack race, we can't federally mandate good sense and health, but that doesn't mean private industry and groups can't lead our nation to healthy (and less costly healthcare) outcomes.

As mentioned in the post, I think the focus of many young liberals is that universal healthcare is the magic silver bullet to make the country a better place, but it's neither the primary solution nor the stopping point. But hey, the #1 rule of politics is simplify for your audience...

[mrsleeve]

I enjoying reading this debate guys. I am too busy and not as well educated on this as I should be..

Other than to say I am all for the repeal of the 0's law, and am not against the idea of reform at all. I just feel that we need to think it over and needs to very well thought out and crafted, careful and prudent legislation. Especially with out all the shit in there having to do with education, school loans and so on.

[KenC]

That makes logical sense, but would Obamacare actually do anything for that? Or instead of tackling the real issues, it throws up a red herring of coverage? [After which, the liberals declare victory and stop caring about underlying concerns rather than blanket solution]

*********
All that you hear about is the mandate, but there are several great aspects of it.

Monetary incentives to implement Electronic Health Records (EPIC is an incredible tool, very expensive and out of reach of most small clinics.)

More funding for the National Service Corp to incite health professionals to practice in undeserved areas.

Establishment of Accountable Care Organizations. Kind of an overseer of coordination/management.

Free preventive care (physicals, blood work, sigmoidoscopies, etc). Great incentive to get people in, and cheaper in the long run for insurance companies.

Direct reimbursement for providers for assisting patients with end of life planning or advanced directives.





Yeah, there's multiple industries being discussed as one, but how many companies in each direct care, administration, and devices actually being truly innovative or novel rather than simply "managing"? Are any health networks of physicians working to align care delivery? Are plans working to streamline non-valued work (and employees) to maximize patient health and care for their premiums taken? Are device and technology companies looking at any high risk ideas rather than simply polishing the same thing year after year?

*******
I can't speak intimately about the device companies. However, most large HMOs and academic health centers (OHSU, Mayo Clinics, etc) are working very hard to provide effective and efficient care to their patients. The HMO that I work for is well known for its clinical research and is at the forefront of developing evidenced-based treatment guides. Family docs can get on the intranet and view treatment and diagnostic algorithms that are written by specialty department chiefs.

In regards to the devices, I've only really ever been involved with joint replacements. Companies like Smith & Nephew and Johnson & Johnson are always trying to come out with a new "improved" revision of their prosthesis to try and capture a larger market share. At least this industry is largely market driven. The hospital I work at performs more knee replacements than any other surgery, so there's a boatload of money to be made. The number one question patients would always ask the surgeon I worked with was "how long will this last?". His answer was always the same: "I don't really know." A "new and improved" revision came out pretty frequently so there is hardly any clinical evidence to suggest that they were better than the previous generation.
Right now, there's a huge debacle with metal on metal hip replacements. It was thought that they would last for a persons lifetime, but the metal ions are causing irritation some 5-7yrs down the road.



[Health care plans] You mentioned required % of premium going to direct care before, but does the industry track and publish that?

****
I'm not certain, though I'm sure it could be acquired.

[KenC]

I enjoying reading this debate guys. I am too busy and not as well educated on this as I should be..

Other than to say I am all for the repeal of the 0's law, and am not against the idea of reform at all. I just feel that we need to think it over and needs to very well thought out and crafted, careful and prudent legislation. Especially with out all the shit in there having to do with education, school loans and so on.

Yeah it's nice when somebody has the cognitive capability to carry on constructive dialogue lol. I always like to be forced to think critically.

I think you're referring to the college loan forgiveness bill? Was that part of the ACA?
In any case, I'll use that as a lead-in to my impending economic situation and then relate that to the physician "shortage" we have.
In four years, I'll accumulate an estimated $278,000 in debt with an interest rate of about 7.5%. I'll be required to repay the debt within ten years. I'm not even sure what my monthly payments will be.
Physician compensation varies possibly greater than any other industry. Family Practitioners average around $175k, while Dermatologists average closer to $300k. With a huge pile of initial debt and astronomical specialty compensation rates, it's no wonder we have a huge shortage of Primary Care docs. There was an article in The Oregonian a few years ago about OHSU's Internal Medicine resident graduates, and how only one out of the 20+ was going into primary care instead of continuing on with a specialty fellowship. Don't get me wrong, the majority of specialists love their niche in the medical world, but if somebody is one the proverbial fence about residency programs, I can't blame the one that's going to net them millions more over their life time.
This is a serious issue that needs to be addressed more aggressively. There are loan repayment programs for serving as a primary care doc in an underserved region, but it's really not at the magnitude that it needs to be to really tackle the problem.

[rwh11385]

I enjoying reading this debate guys. I am too busy and not as well educated on this as I should be..

Other than to say I am all for the repeal of the 0's law, and am not against the idea of reform at all. I just feel that we need to think it over and needs to very well thought out and crafted, careful and prudent legislation. Especially with out all the shit in there having to do with education, school loans and so on.

You mean to think that this whole thing was rushed into a bit and included in a pile of 2700 pages of guvment policymaking that few people could ever manage with an infinite amount of Ritalin? Yes, it's clear that improvements need to be made in the industry... but giving up freedom to do so isn't great either. Of course everyone should have HCI... but what else would the government mandate of its free citizens? It cannot force an industry to magically be 'more free market', efficient, effective... but too many cooks in the kitchen can make it much more effort to deal with regulations, forms, whatever government throws at us. Too much policy, not enough action of people "on the ground" dealing with the problems making the solutions.

Yeah it's nice when somebody has the cognitive capability to carry on constructive dialogue lol. I always like to be forced to think critically.

I think you're referring to the college loan forgiveness bill? Was that part of the ACA?
In any case, I'll use that as a lead-in to my impending economic situation and then relate that to the physician "shortage" we have.
In four years, I'll accumulate an estimated $278,000 in debt with an interest rate of about 7.5%. I'll be required to repay the debt within ten years. I'm not even sure what my monthly payments will be.
Physician compensation varies possibly greater than any other industry. Family Practitioners average around $175k, while Dermatologists average closer to $300k. With a huge pile of initial debt and astronomical specialty compensation rates, it's no wonder we have a huge shortage of Primary Care docs. There was an article in The Oregonian a few years ago about OHSU's Internal Medicine resident graduates, and how only one out of the 20+ was going into primary care instead of continuing on with a specialty fellowship. Don't get me wrong, the majority of specialists love their niche in the medical world, but if somebody is one the proverbial fence about residency programs, I can't blame the one that's going to net them millions more over their life time.
This is a serious issue that needs to be addressed more aggressively. There are loan repayment programs for serving as a primary care doc in an underserved region, but it's really not at the magnitude that it needs to be to really tackle the problem.

Obamacare was the legislation that had the federal government take over all the standard and PLUS loans for college students. (And the website you need to take your "I understand I have to pay this back" training at sucks and is incredibly flawed in design...) Instead of Sallie Mae and other banks financing students, it's the Feds directly and private loans only being for when you borrow over $12,500 a year, etc. (for undergrad at least).

Not really sure why that happened... but it's certainly more of an annoyance now.

Is that why my friends are challenged to find a new doctors in the area they move to? A friend with allergies and swelling kept getting told they weren't taking new patients. And I thought money wasn't everything to a doctor?? Oh well, we could certainly use more people making a positive impact in the nation/world with health and other problem areas, like energy... rather than just writing about it on Apples in coffee shops while making OWS posters. Talking about a problem, and then procuring the skills, knowledge, and ability to do something about it are vastly different things. So is working to fix the situation, and wanting to seem like you are to remain popular with your voters who want it fixed when you get re-elected...

[KenC]

You mean to think that this whole thing was rushed into a bit and included in a pile of 2700 pages of guvment policymaking that few people could ever manage with an infinite amount of Ritalin? Yes, it's clear that improvements need to be made in the industry... but giving up freedom to do so isn't great either. Of course everyone should have HCI... but what else would the government mandate of its free citizens? It cannot force an industry to magically be 'more free market', efficient, effective... but too many cooks in the kitchen can make it much more effort to deal with regulations, forms, whatever government throws at us. Too much policy, not enough action of people "on the ground" dealing with the problems making the solutions.




Obamacare was the legislation that had the federal government take over all the standard and PLUS loans for college students. (And the website you need to take your "I understand I have to pay this back" training at sucks and is incredibly flawed in design...) Instead of Sallie Mae and other banks financing students, it's the Feds directly and private loans only being for when you borrow over $12,500 a year, etc. (for undergrad at least).

Not really sure why that happened... but it's certainly more of an annoyance now.

Is that why my friends are challenged to find a new doctors in the area they move to? A friend with allergies and swelling kept getting told they weren't taking new patients. And I thought money wasn't everything to a doctor?? Oh well, we could certainly use more people making a positive impact in the nation/world with health and other problem areas, like energy... rather than just writing about it on Apples in coffee shops while making OWS posters. Talking about a problem, and then procuring the skills, knowledge, and ability to do something about it are vastly different things. So is working to fix the situation, and wanting to seem like you are to remain popular with your voters who want it fixed when you get re-elected...

Those loans were always federally backed/insured anyway. All they did was cut the middleman out.

[rwh11385]

Those loans were always federally backed/insured anyway. All they did was cut the middleman out.

So are all banks (FDIC)... should the government cut out the middleman with them too?

And Feds don't give me a 5% bonus for paying a year on time.

[KenC]

http://www.nytimes.com/2012/03/31/op...for-death.html