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View Diary: Medicare: What can we do about it? (314 comments)

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  •  Great article (3+ / 0-)
    Recommended by:
    DemFromCT, Catte Nappe, TexasTom

    the only other thing I would add is the extent to which relative productivity is driving health care costs.  The theory,  created to explain the cost of rising theater prices notes:

    The rise of wages in jobs without productivity gains is caused by the necessity to compete for employees with jobs that did experience gains and hence can naturally pay higher salaries, just as classical economics predicts. For instance, if the banking industry pays its bankers 19th century style salaries, the bankers may decide to quit and get a job at an automobile factory where salaries are commensurate to high labor productivity. Hence, bankers' salaries are increased not due to labor productivity increases in the banking industry, but rather due to productivity and wage increases in other industries. [theft has something to do with it as well, but that is another story]

    The original study was conducted for the performing arts sector. Baumol and Bowen pointed out that the same number of musicians are needed to play a Beethoven string quartet today as were needed in the 19th century; that is, the productivity of Classical music performance has not increased. On the other hand, wages of musicians (as well as in all other professions) have increased greatly since the 19th century when not adjusted for inflation.

    In a range of businesses, such as the car manufacturing sector and the retail sector, workers are continually getting more productive due to technological innovations to their tools and equipment. In contrast, in some labor-intensive sectors that rely heavily on human interaction or activities, such as nursing, education, or the performing arts there is little or no growth in productivity over time. As with the string quartet example, it takes nurses the same amount of time to change a bandage, or college professors the same amount of time to mark an essay, in 2006 as it did in 1966.

    This means that there are two powerful factor that will drive health care cost increases, relative productivity and demographics.

    It also means efficiency gains from something like a public option are even more important.

    The bitter truth of deep inequality has been disguised by an era of cheap imported goods and the anyone-can-make-it celebrity myth - Polly Toynbee

    by fladem on Sun Aug 21, 2011 at 09:41:08 AM PDT

    [ Parent ]

    •  great comment (2+ / 0-)
      Recommended by:
      Justanothernyer, joedemocrat

      though there are big productivity gains in medicine such as through EMR (that's theory! and not yet realized) as well as tele medicine. there are things that can be done to decrease the time spent with a patient 9not always great!) and improve the number of patients a provider can see 9electronic scheduling.) Medicine is not as static as a Beethovan quartet.

      "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

      by Greg Dworkin on Sun Aug 21, 2011 at 09:49:50 AM PDT

      [ Parent ]

      •  RE: EMRs (4+ / 0-)

        I know I've been a relative naysayer on this, but the productivity increases have absolutely not been realized; in fact, almost all of the companies who produce these systems recognize a 5 to 10% cut in productivity even out as long as two years - at tremendous cost. Any idea what the licensing costs are for them?

        I've worked on three systems. At the beginning of the visit it's okay, I can pay attention to the patient and type at the same time. It's when it comes to ordering things that I have to completely divert my attention from the patient to the computer. Part of it is that the system I'm on now is, frankly, awful.

        And here's another thing: they don't talk to each other and unless there is access to the information contained within, they are fairly nigh useless. Not so bad for putting information in, but lousy for getting information out. And generally when administrators are looking at systems, they aren't looking at whether you can get information out or not, other than what can be audited for "compliance."

        I've said it before, but I have a good friend who is a reasearcher in AI and works on one of the major systems in this country, who says we are not going to have a truly functional system in our lifetimes. When I talk to programmers and systems analysts among my patients, they almost universally agree.

        Not only is medicine not as static as a Beethoven quartet, medical decision making is very complex and does not lend itself well to the I/O quality of computer systems, nor to the silo approach to medicine that is all that these systems are capable of - and which Medicare is looking at in terms of its so-called "quality" measures.

        Frankly, no wonder so many good docs are going the retainer route. It's about more than money.

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

        by stitchmd on Sun Aug 21, 2011 at 12:46:38 PM PDT

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        •  no question, and yet... (0+ / 0-)

          within large groups I have seen the pt visits icrease (eschaduling a huge help, now and not in the future), e-billing and collection improve and _within the group who call all read the damn thing-  less duplicative tests ordered,.

          "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

          by Greg Dworkin on Sun Aug 21, 2011 at 12:55:59 PM PDT

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          •  Re: billing (0+ / 0-)

            really, that's what the systems are all about, and that's how administrators choose them. Not all systems are set up well for coding, however (the one on our current system is flat-out terrible.)

            I will agree about the duplication of tests, but that is dependent on the ability to get data out. And if the test is done on a system that doesn't talk to the current system, then you're just back to the same old, same old crap of calling, dealing with HIPPA, etc.

            The wide variation in systems, and the proprietary nature, can make many providers especially ones in smaller groups or independent practices feel like it's a huge boondoggle.

            Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

            by stitchmd on Sun Aug 21, 2011 at 02:44:08 PM PDT

            [ Parent ]

            •  yes (0+ / 0-)

              as i said, the potential, not the actuality, but in some cases benefits are seen now.

              "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

              by Greg Dworkin on Sun Aug 21, 2011 at 03:04:46 PM PDT

              [ Parent ]

              •  and while I agree in part (0+ / 0-)

                the problem is that the mandates, and the costs, are out there already. And penalties are about to kick in. Asking small providers to pay these costs with minimal benefits to themselves or to their patients, especially with the limited systems available out there (and the better products aren't even really available to independent practitioners or small groups) is extremely hard to defend.

                Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

                by stitchmd on Sun Aug 21, 2011 at 03:18:30 PM PDT

                [ Parent ]

                •  there'll need to be partnering with local hospital (0+ / 0-)

                  systems, and there'll be a need for integrated health systems. The future, like it or not.

                  "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

                  by Greg Dworkin on Sun Aug 21, 2011 at 03:57:20 PM PDT

                  [ Parent ]

                  •  I recognize the benefits (0+ / 0-)

                    and I recognize what is probably greater, the potential for benefits. I don't mind using them, either; I've gone back and forth over the past 2 years and I feel like I see the good and bad of both.

                    What I don't like, however, is the idea that this is going to be the "savior" of medical care, that it's the best thing ever. There are limitations. And these systems do nothing to support complex decision making; in fact, in some cases, the limitations on documentation (linked into the horrendous coding system) impede it. The other thing I don't like is the imposition of the system on physicians who really can't afford it and the restrictions the mandate places on their ability to practice medicine (and I say that as someone who has always been employed.) When we got to EMR, the hospital takes the overhead of the cost and supports the salary during implementation. No such benefit for private practitioners.

                    We have a long way to go and there's a whole heck of a lot of room for improvement.

                    Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

                    by stitchmd on Sun Aug 21, 2011 at 04:22:31 PM PDT

                    [ Parent ]

      •  And of course (1+ / 0-)
        Recommended by:
        DemFromCT

        you may need fewer musicians given modern sound technology.

        This is not static as you rightly note, but the implications are serious and suggest that government will need to take a larger share of GDP to provide the same level of service since two of the things it provides (Education, Health Care) are likely to see less productivity increases than other industries.  This implies that governments will see continual financial pressure unless they adapt their taxation schemes to adjust for the effect Baumol describes.

        This gets more complicated the more you study it, but I have seen OECD research papers trying to think about the implications.

        One can be seen in the UK: where the fees for public Universities this year are going from three thousand pounds to nine thousand pounds.  

        The bitter truth of deep inequality has been disguised by an era of cheap imported goods and the anyone-can-make-it celebrity myth - Polly Toynbee

        by fladem on Sun Aug 21, 2011 at 02:42:11 PM PDT

        [ Parent ]

        •  important points (0+ / 0-)

          thank you! again, maximizing cost efficiency helps with those pressures.

          "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

          by Greg Dworkin on Sun Aug 21, 2011 at 03:06:05 PM PDT

          [ Parent ]

    •  There is the 'productivity' (5+ / 0-)

      of deriving maximum profits from minimal effort.

      I confess to only skimming the article, but I see something interesting happening (as the POA for healthcare for my aging father, a WWII veteran who is now in nursing care.)

      What I see from here is a medical community that uses Medicare as a money pump.

      It is not necessarily the patients themselves who are driving up redundant costs. Here are a few of the activities I have witnessed and continue to witness on a regular basis:

      Physicians ordering tests of spurious necessity.

      Physicians spending less than 10 minutes with a patient and going over his/her chart, and then billing for an hour.

      Physical therapists billing for one-one one therapy while giving group exercise sessions, and/or padding the time. This is a biggie.

      Outside (contracted) service providers performing basic nail trim/pedicures and billing for $100 nail debridement procedure.

      Eyecare and dental care, also at higher cost and unnecessary frequency.

      My Dad, as a veteran in nursing care and can receive all of his medical care from the VA medical center (which happens to be 300 yards from the nursing home) AT NO COST TO him. instead, the nursing home uses these services for the sake of expediency (i.e THEIR bottom line)

      So, I have to be on constant alert or we get buried under a blizzard of co-pay bills, for services not adequately rendered, or services which could have been rendered by the VA

      The other boondoggle is medication but I'll save that for another rantpost.

      The point here is that I see a lot waste, padding and outright fraud occurring at an institutional level. Families virtually coerced in to going along with this boondoggle.

      And I suspect that it gets far worse when nursing home patients run out of funds and go on Medicaid: then there is no opportunity for a family watchdog like myself to look at the bills.

      They do this because they can.

      "When the going gets weird, the weird turn pro." Hunter S. Thompson

      by SNFinVA on Sun Aug 21, 2011 at 10:33:05 AM PDT

      [ Parent ]

      •  How can this get better... (0+ / 0-)

        ...when an increasing amount of medical costs are paid by a 3rd party.  If something is free, or close to it, people don't pay attention to price signals.  

        One of my concerns with ACA is that it doesn't allow for the kind of experimentation taking place in states and in the private sector with HSAs, high deductible plans, etc.  

        I don't see how the federal gov't can run a one-size-fits-all system without ending up with the kind of fraud and abuse we see under the current system.  Can we really trust Congress to fix it when they all take bribes from the health care industry?

        •  It doesn't? (1+ / 0-)
          Recommended by:
          LillithMc
          ACA is that it doesn't allow for the kind of experimentation taking place in states and in the private sector
           I thought there was room for pilot projects of various sorts.
          So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.
          Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

          It's a very interesting Atul Gawande article

          •  The gov't track record... (0+ / 0-)

            ...for innovation is pretty weak.  The incentives for most gov't employees is to maximize their budgets and keep their jobs.  How can we expect MORE innovation than we already have with Medicare by making the system even bigger.  

            I think gov't can be the payor, but if we don't find a way to empower people to make choices, I don't see how we can bend the cost curve.  People spend other people's money differently than their own.

        •  In France (1+ / 0-)
          Recommended by:
          denise b

          the patient pays for outpatient stuff and then awaits reimbursement (except 1 Euro) from his/her insurers.

          Care is basically free, but the patient has an incentive to watch the cash flow.

      •  I agree with you (0+ / 0-)

        although the per piece billing for physicians is not based on time, unless they actually go over an hour - and the amount of documentation required to support that billing takes up more than that amount of time.

        I've had my own issues with problems my parents are having, my father calls me about bills all the time, most recently for a test ordered for my mother which was of dubious benefit as I told him, but the ordering cardiologist said it was absolutely necessary and needed to be done right away, but might not be covered by insurance (honestly, that should be a red flag for ANYONE right there.) My father paid up front for the test but talked to the insurers to get it covered; due to his persuasiveness he got them to approve coverage for it. He recently called me, rather indignant, to find that it was never submitted for a claim to his insurance. I said 'of course not, they would have to accept Medicare rates and what you paid them was more; why would they want to try to get less payment?'

        To me, this whole episode shows so much of what the problems are in our medical system, especially that it is all about making money - and you wonder why it's 20% of our economy.

        But then again, my father is a typical person who, if the doc tells him something needs to be done, he wants it done yesterday. He wants his MRI done for his headache even as he complains about the overuse of these procedures and the cost.

        And you wonder why we are where are...

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

        by stitchmd on Sun Aug 21, 2011 at 02:25:01 PM PDT

        [ Parent ]

    •  No Credibility (0+ / 1-)
      Recommended by:
      Hidden by:
      cville townie

      Anyone that thinks that a public anything is more efficient than a private anything is no one to even be considered relevant on the subject...

      •  SS, IRS, your local fire deprtment (0+ / 0-)

        c'mon.

        "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

        by Greg Dworkin on Sun Aug 21, 2011 at 04:47:19 PM PDT

        [ Parent ]

      •  also Navy SEALS (1+ / 0-)
        Recommended by:
        kalmoth

        and anyone who uses the name Barry to describe the president is a troll.

        "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

        by Greg Dworkin on Sun Aug 21, 2011 at 04:49:12 PM PDT

        [ Parent ]

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