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  •  no, it's not fine (1+ / 0-)
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    wsexson

    everyone wants to blame all the costs on insurance companies, and gd knows I'm not defending them, but there are enormous other costs that have to be addressed and cut back.

    There are folks whose jobs involve selling things to docs - drugs, medical devices, services, etc. They often make more than the docs themselves. Know cardiac stents? The stent reps make more, on average, than the cardiologist - and cardiologists make $300K per year, or more (some do make less, but they are not the ones who put in the stents.)

    I was looking for jobs for internal medicine, and a google search for such came up with a sales job where the starting salary was about $140K - and there were bonuses, too; total compensation was expected to be well above $200K. The average salary for an internist in my area is under $150K.

    I could give you loads of other examples.

    Not to mention docs who over order tests because of subtle kickbacks like cross referrals, and other incentives, well described in Atul Gawande's New Yorker article.

    "Healthcare" has become big business above and beyond the insurance companies. Lots of people want a piece of that pie, and are going to do whatever it takes to protect that piece if they already have it.

    "Stakeholders," indeed.  

    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 Sat Jul 25, 2009 at 10:27:12 AM PDT

    [ Parent ]

    •  Agree to disagree... (0+ / 0-)

      we need new technology and innovation in healthcare...

      Obama - Change I still believe in

      by dvogel001 on Sat Jul 25, 2009 at 10:50:13 AM PDT

      [ Parent ]

      •  toward what end? (0+ / 0-)

        seriously. We have loads of technology for those who can afford it and loads more people who can't access basic care. Again, is that ethical? Just?

        And I don't know how familiar you are with how such 'technology' gets approved, but the approval for medical devices, for example, is far, far less stringent than that for drugs. All a medical device has to prove to be approved is that it doesn't hurt. It doesn't have to prove effectiveness, it doesn't have to prove that it's better than the alternative.

        And so people wind up with multiple stents in a single coronary artery, at $30K per, and there's not a single study out there that proves that that's more effective than medical therapy. Certainly nothing proves it's more effective than bypass surgery.

        Here's another thing about technology - it's great to not have to do exploratory surgery on patients when you can do an imaging study like a CT scan to look for what the trouble may be. CT scans were first used outside of just research in the late 70s, and came into widespread use in the 80s, with MRI becoming big in the 90s. Now, if you're a young woman on birth control pills coming into the ED with chest pain and/or shortness of breath, you have just bought yourself a trip through the spiral CT scanner to see if you have a pulmonary embolism or not.

        Thing is, radiation doses are cumulative. The body does not significantly recover from many doses of radiation, and radiation damage gets worse over time. We're starting to see the effects of that on people who have had multiple scans involving radiation therapy. And this has taken many forms, including increased cancer rates in some people.

        And we have Gardasil, a great success in term of prevention of HPV, but we have way too many women who can't even get regular Pap smears. And the epidemiology is very clear that the vast, vast majority of women who develop cervical cancer in this country are women who have gone more than 5 years without having a Pap smear. And Gardasil has not been shown to decrease the rate of cervical cancer, it's deceptive ads notwithstanding.

        We have to decide: do we want technology, or do we want basic care. Do we want CT scanners on every corner, or do we want to be able to reach people like those in the diary for basic dental care and essential screening services.

        Don't tell me we can do it all. We can't. We've been living on the big credit card for too freaking long now. We've got to get over this idea, perhaps born out of a sense of American exceptionalism, that we can have it all and we can have it now, and it won't cost anything.

        Because it does. Everything has a cost.

        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 Sat Jul 25, 2009 at 12:56:31 PM PDT

        [ Parent ]

        •  I understand your concern... (0+ / 0-)

          My father who had bypass 20 years ago has been kept alive by stents and it has reduced his chance of a heart attack and death by having multiple angioplastis and stents...

          When my dad had his bypass 20 years ago...he almost died due to complications...nothing that serious has ever happened to him from angioplasti procedure...

          The whole area of having minimally invasive surgery which is more technology challenging but less recovery time and less stressful on the body is an area that is very promising on more technology leading to better outcomes and less cost procedures...

          So I say we can have it all and it is not all about doing less...to save money...

          My dw who has stage 2 breast cancer has an innovative treatment that is more expensive but more effective from Memorial Sloan Kettering...it is taking the same medications but giving them in a more concentrated fashion (every 2 weeks instead of 3 with a imune booster drug that cost $2500 per dose).  But the cancer treatment is more effective and less taxing on the patient......

          That is clearly worth it in my opinion...MSK decided on this treatment regardless of cost...but based on effectiveness..but a doctor visiting from Canada said that this treatment was not available in "poorer countries"...

          So in the end....I am not against expanding medical availability to all but I am against rationing care in the greatest country on earth.../peace...

          Obama - Change I still believe in

          by dvogel001 on Sat Jul 25, 2009 at 09:21:01 PM PDT

          [ Parent ]

          •  okay, (0+ / 0-)

            but as for these treatments, (and I can tell you I've seen plenty of really awful outcomes after experimental treatments, hate to say it) would you be all for it if you had to bear the true costs?

            You have insurance which covers those costs, but your premiums alone, whether paid by you or by your employer or both, do not cover the entire costs of that treatment, and probably wouldn't even if you added up what you've paid thus far for the insurance. So you are, in effect, relying upon the "kindness of strangers" to at least partially pay for those very expensive treatments. Do they not get a say in how their money is spent?

            That's the issue we must deal with as we take on the issue of healthcare costs as a society. We cannot pay for everything, regardless of what you might think. We simply can't. And so we have to determine what the best use of the society's funds is for the society at large, and that means that some individuals are going to get left out. There's no avoiding that unless we want healthcare to account for 40% or 50% or GDP as opposed to the 16%+ we have right now.

            You've even admitted we ration care on the basis of the ability to pay. That is not likely to be accepted under a society-wide plan; in fact, it's exactly that which is being rebelled against by the society and is pressing the calls, the screams, for reform. It has the potential to really get people into the streets, although that does seem to take a hell of a lot in this country these days.

            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 Jul 26, 2009 at 03:48:17 AM PDT

            [ Parent ]

            •  I am not talking about experimental... (0+ / 0-)

              treatments...experimental treatments for the most part are not covered by any insurance unless you are in a clinical trial...

              These are all approved treatments...for all non-experimental treatments...we should provide the best procedure, process, medicine that is available regardless of cost that provides the best outcome and the least overall risk to the patient...

              If you are trying to sell that we should all sacrifice our medical care so all can get care...you will lose that battle...

              It has to be sold like POTUS Obama said...nothing will change if you are happy with your healthcare...the only thing that will change is that if you do not currently have access to healthcare due to some issue...you will under this plan...

              There are always people who have catastrophic medical costs...those costs must be shared across the population equally...selling that we cannot have our cake and eat it too...is the wrong way to go...

              We have to sell it that places like MSK are much more efficient at delivering cancer care because of coordination of all procedures through a central process that makes sure only one test is given instead of 5 different doctors ordering 5 different tests...but nobody should say to a doctor at MSK...hey I know that treatment is proven more effective for curing that cancer...but you should use the less expensive one anyway...

              Obama - Change I still believe in

              by dvogel001 on Sun Jul 26, 2009 at 07:46:30 AM PDT

              [ Parent ]

              •  you cannot provide anything regardless of cost (0+ / 0-)

                aren't you an accountant? I would think that you would certainly understand costs.

                There is no free lunch. There is no free healthcare.

                Are you willing to pay the taxes or the insurance premiums necessary to guarantee that everyone can have everything that is the best procedure regardless of cost? Please, really, answer that and please don't dodge it the way you did the question about morality.

                There are hard decisions to be made. If you're not willing to "give up" what you've got to make them, fine. You're right, that's going to be what decides this deal, whether it lives or dies itself.

                But, and I mean this truly honestly, I hope you never find yourself in a position where you lose your insurance or don't have access to a plan that will provide coverage, because from what you've described about your own family's history, you'd very likely be uninsurable at any cost under our current system.

                And then, seriously, will you be able to pay for "the best treatment?" Because I assure you, you would then find out the truth about the costs.

                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 Jul 26, 2009 at 09:34:47 AM PDT

                [ Parent ]

                •  Yes I am... (0+ / 0-)

                  and sometimes the best treatment is less cost than the 2nd best treatment.  Take minimally invasive surgery vs conventional surgery...the surgery may be more expensive but since the recovery time is cut down by 75% the total cost is lower...

                  Yes, we should pick the most effective treatments for diseases and procedures regardless of cost...if we do that...it will all work out in the end...

                  As for my insurance situation...I am fortunate to live in NJ that has regulations in place that forbids denial based on pre-existing conditions and mandates community rating for premiums...so the cost is spread to the entire population as it should be...

                  Keep on trying to sell this as those with good coverage have to give up their good healthcare...and you will get nothing...I am for reform and insuring those without coverage...but not at the expense of my healthcare...and that is the majority of opinion in this country...

                  As POTUS Obama put it in his press conference...many people are wary...they do not necessarily like the current situation but it is better than the devil I don't know...and the devil you are describing is even worse...

                  Obama - Change I still believe in

                  by dvogel001 on Sun Jul 26, 2009 at 10:15:07 AM PDT

                  [ Parent ]

                •  You are right... (0+ / 0-)

                  healthcare is not free...and we should be willing to pay for the best healthcare available in the world...we are America...the best country in the world...

                  Obama - Change I still believe in

                  by dvogel001 on Sun Jul 26, 2009 at 10:16:05 AM PDT

                  [ Parent ]

                  •  We aren't getting the best healthcare now (0+ / 0-)

                    if you measure it by outcomes data, life expectancy, etc. That is very clear even if as you keep trying to push the idea that this is the "best country in the world." But whatever. And you still dodged the question of whether you would be willing to shoulder the true costs of that kind of care.

                    But hey, the risks are spread evenly in your community, as you say it should be - but you are unwilling to say that you would give up one iota of what you think you deserve.

                    Pardon me for sounding like I'm attacking you personally. It isn't personal, I've heard way, way, way too many people make exactly the argument you're making. I want what I want, and damned the expense, because we are the "best country in the world." But damned if I'll really pay for it.

                    And that is why we can't achieve real reform in this country. And why so many people remain uninsured. Even in your home state of New Jersey. Even in mine which has similar restrictions.

                    There is no such this as "efficiencies." People have been saying for years, for example, that they are going to cut the cost of government by getting rid of "waste" and "bureaucracy" and "abuse." How well has that worked, eh?

                    What you are proposing for healthcare is the same thing. But you'd need to provide more specifics of what can be cut, what can be provided in terms of efficiencies, before it means anything more than a bunch of hot air.

                    Frankly, look at yourself in the mirror and ask yourself if you really want reform. Be honest with yourself. Really.

                    From everything you've said, and as you've pointed out, your view is pretty common, if it means that you'd lose even one iota of what you've got, you couldn't frankly give a damn if other people are uninsured. Unless it could be proven to you that it raises your costs (and that data is out there.)

                    And so it is with the majority of the citizens of the "best country in the world...."

                    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 Jul 26, 2009 at 12:54:53 PM PDT

                    [ Parent ]

                    •  As someone who unfortunately... (0+ / 0-)

                      has had to consume way too much healthcare for me and my family I can tell you the incredible waste of the system that has nothing to do with choosing inferior care to save money or forcing people to wait months for "elective surgery"

                      Examples are:  

                      1. Keeping patients in the hospital for extra days until their drains stop draining rather than sending them home when they are ready and having a nurse practitioner visit you for 3 visits to make sure your drains are clearing.  When I had surgery they had to keep me in the hospital when I was feeling fine for 5 extra days until the drains stopped draining.  Even then they took one drain out too soon which caused me to have to be re-admitted into the hospital for another 5 days with complications.  Why did they rush trying to take that drain out...because I was over the allotted time in the hospital on a negotiated fee for that procedure.  So if they did what they did for my wife and just train me and or give me some nursing support at home, I could have saved money, been more comfortable and there would have been no pressure to take out the drains early.  Total cost of the procedure/hospitalization $250K total additional cost $50K.

                      There are numerous examples that could have cut down my considerable medical expenses while improving quality and not having to choose an inferior procedure due to cost considerations...

                      Obama - Change I still believe in

                      by dvogel001 on Sun Jul 26, 2009 at 04:40:20 PM PDT

                      [ Parent ]

                      •  when I was in residency (0+ / 0-)

                        and later, we had good access to home health care, and we'd send people home all the time with the kind of care that you are talking about. Then some people came in to cash in on it, and then started bragging about how much money they made on it, and all of a sudden the coverage was cut back dramatically or eliminated.

                        The whole issue of readmission to the hospital has to do with an inadequate system for outpatient care and lack of communication between inpatient and outpatient doctors, which has only gotten worse with the rise of the hospitalist movement (I'm not opposed to this, btw, but it requires good communication) and turning over most post-operative care to mid-levels, the frontpage diary on PAs notwithstanding. Until we address that problem, we're going to have problems with hospital readmission rates.

                        System is FUBAR.

                        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 Jul 26, 2009 at 04:46:51 PM PDT

                        [ Parent ]

                        •  And we come full circle... (0+ / 0-)

                          in my wife's case it is all coordinated and they are all part of the treatment plan from MSK...so there is no waste, fraud and abuse...they planned 3 visits, we needed 3 visits, insurance approved 3 visits...and that is the way it should be...

                          Obama - Change I still believe in

                          by dvogel001 on Sun Jul 26, 2009 at 05:19:10 PM PDT

                          [ Parent ]

                  •  and I'll ask you one more time (0+ / 0-)

                    if you had to pay that $2500 dollar cost of your wife's medication (I'm assuming it's GCSF or something similar) every 2 weeks, would you? Would you if your insurance didn't cover it? Would you do it if the full cost of the more standard therapy was completely covered by your insurance, but this program is not? And do you know what the 'marginal' benefit of this is, anyhow?

                    Would you be willing to pay that cost?

                    Once again, I ask you not to dodge. You haven't answered directly any question I've asked yet.

                    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 Jul 26, 2009 at 12:59:33 PM PDT

                    [ Parent ]

                    •  Yes...If the doctor's said it was... (0+ / 0-)

                      the best case (which they did) for preventing recurrence of cancer...I would pay every penny...

                      My wife is 44 years old...you have basically 1 chance to get rid of the cancer (80% survival rate in stage II)  after that if it recurs it is a 20% survival rate...that means you should throw the kitchen sink at it in the first round because you basically only get one realist shot of killing the cancer...

                      In the scheme of her life $20,000 is a small price to pay...(8 x $2500)...

                      But I also believe that just because I am willing to pay for it others should not have to forgo the best and most effective treatment...

                      Obama - Change I still believe in

                      by dvogel001 on Sun Jul 26, 2009 at 02:50:43 PM PDT

                      [ Parent ]

                      •  here's the thing about it, though (0+ / 0-)

                        I've been in practice long enough to have seen a myriad of treatments for breast cancer come and go. I truly wish the best for your wife and I hope she beats it. Pre-menopausal breast CA is a beast, but many people do well - 80% as you say.

                        But the thing that has been shown over the past few years is that more is not always better. When I was in training and coming out of it (and I almost went into an oncology fellowhip) the big deal was to do fully ablative chemotherapy and then do a bone marrow or stem cell transplant. What was found was that the toxicity and risks (especially of the transplant not engrafting or not fully, I saw cases related to that which were truly ugly) were not outweighed by higher disease free survival rates and that overall survival was not better.

                        Yes, I'd give it a full guns gonzo blast, too. I'm the same age, and I have kids.

                        And I appreciate that you recognize and would be willing to pay the cost. It's not an option even open to most people.

                        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 Jul 26, 2009 at 03:12:07 PM PDT

                        [ Parent ]

                  •  and just for your interest (0+ / 0-)

                    here's a link to the abstract first discussing intensive breast chemotherapy treatment. There was a non statistically significant trend toward increase in disease free survival; the toxicity of the treatment was much higher independent of the immunosuppressive effects. It's a far from settled deal that this improves the outcomes, sorry to say. And yes, this is the kind of study that would deserve close scrutiny if there were to be evaluations of what might be covered.

                    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 Jul 26, 2009 at 01:05:41 PM PDT

                    [ Parent ]

        •  My parents have basically been kept... (0+ / 0-)

          alive on stents for the past 15 years and have made it to their 50th anniversary seen 4 grandchildren born and their oldest grandchild bat mitzvahed...yes that is worth the cost of stents...

          And I am well aware of the FDA process for approving medical devices...I have many clients over the years with companies that manufacture such devices...

          Obama - Change I still believe in

          by dvogel001 on Sun Jul 26, 2009 at 10:27:05 AM PDT

          [ Parent ]

        •  But I guess keeping someone alive... (0+ / 0-)

          and active for 15 years is not worth the cost...it would have been cheaper to let them both die...no thanks...call me selfish...

          Obama - Change I still believe in

          by dvogel001 on Sun Jul 26, 2009 at 10:28:22 AM PDT

          [ Parent ]

          •  that is not my point (0+ / 0-)

            and btw, my mother had stents in the early days and underwent cardiac bypass surgery in 2002 at the age of 75. I'm not saying let anyone die.

            And I can remember, back in the day, when I was a med student and a well-known nonagenarian patient was admitted with chest pain. The attending cardiologist was quite the hotshot (he was one of the first really aggressive invasive cardiologist, I wouldn't be surprised if the term "cath jockey" was coined to describe him as I've been told previously) but was very unwilling to take that particular patient to the lab (this was in the days before stents) because the doc was very concerned about the risk of coronary rupture or dissection. But the patient began to have an acute infarct overnight and the doc came in, wound up taking the patient to the lab for angioplasty, and he did just fine.

            But the question is whether multiple drug eluting stents are better than bare metal stents alone. Or, frankly, in many cases whether cardiac procedures are at all more beneficial than medical therapy. The costs are exponentially higher. And I've reviewed the data. The outcome data is not statistically significantly better for the DES than the BMS. But the cost is much higher. Not to mention the potential for complications of having to be on long term anti-platelet agents. The cardiologists who are frankly unable to look at the bigger picture, i.e., the whole patient, routinely refuse to allow patients to come off of those drugs even when needed for life saving surgery, and frequently surgeons won't operate if patients are on those drugs. I've seen it multiple times. Talk about your hidden costs.

            We need comparative effectiveness research. We need to look at outcomes data. We need, frankly, to look at the number needed to treat and the cost per number to treat to prevent certain outcomes. It shouldn't have to be a hard and fast number. I'm not saying every 80 year old should not receive dialysis. I am saying, however, if that 80 year old is demented, contracted, and living in a nursing home, and comes to the hospital in renal failure, that patient should not receive dialysis. Even if she's your mother. Or mine. There is a thing called medical futility and we, as physicians, and as patients, need to recognize that there are times when treatments serve no true useful purpose, and we also need to recognize that sometimes the costs outweigh the benefits. Again, if we had to bear the true costs, we would make those decisions readily, on an individual basis as well as a societal one.

            Of course, there needs to be flexibility, as in the case of the 95 year old with coronary disease.

            And here's one other thing, and it's something we physicians often forget: everything we do has some cost to the patient, even if it's drawing blood which incurs some kind of pain. Some patients are more willing to bear that than others. But we are often not honest with patients about what kind of burden they will bear with the treatments we suggest.

            It is not always appropriate to offer the newest, most fancy, most 'advanced' treatment, when an old treatment will work as well or frankly almost as well.

            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 Jul 26, 2009 at 01:27:39 PM PDT

            [ Parent ]

            •  We mostly agree... (0+ / 0-)

              except who should decide...you think it should be some central planner like in Canada...I think it should be the doctor along with the patient...

              But we mostly agree on that it should be the most effective treatment with the least amount of side effects and risk...I just believe that should be regardless of cost..you think cost should come into the picture..

              The other thing I vehemently disagree with is looking at procedures only based on outcomes...it should also be based on the overall comfort and benefit to the patient...

              So if there are 2 procedures one being bypass that has a 4 month recovery and one being angioplasti which has a 2 week recovery and they are equally effective...then the less invasive procedure should be used...

              Obama - Change I still believe in

              by dvogel001 on Sun Jul 26, 2009 at 02:32:29 PM PDT

              [ Parent ]

              •  but in the latter case (0+ / 0-)

                there are clear guidelines about who should be referred for cardiac surgery. There are far less clear guidelines about who should get stents, and there are no guidelines about who should get multiple drug eluting stents, and the outcomes data does not show a benefit of multiple DES over BMS. And many patients will have a similar outcome with medical therapy alone.

                What I am saying is not that there should be a central decision maker, but we need guidelines, evidence based guidelines, that allow us to make proper decisions for the individual patient. I would not have wanted my active 75 year old mom to not have had surgery based on some arbitrary decision maker, anymore than you would. The problem with evidence based medicine, as I've always said and have always taught the residents, is that studies are done on populations in aggregate, but that the patient in the bed is an individual. You can't determine their particular outcome, just discuss the risks.

                But we don't have enough data out there to even begin to counsel patients appropriately. That's what we need.

                I don't disagree with you, mostly, on what you say about the issues of comfort. When the spouse blew a disk and had neurologic problems related, I knew that if there was a good response to the physical therapy, it would save several weeks of being off work and laid up in recovery - and would still have required PT at the back end. So we saved the costs of surgery, not only monetarily but also in terms of time and pain of surgery. However, had there not been some improvement, let me tell you I would have been on the phone to my friend the neurosurgeon pronto.

                But too many people think the first thing is to cut, and the idea of watchful waiting is not acceptable. A few years back, my mom, again, had problems with her knee. She'd had problems with her knee for a long time, but it got worse over a several week period. My parents called their regular doc who suggested she see a particular orthopedist, who was supposed to be the best in the area. But it was going to take several weeks to get in to see him, and my dad found that to be unacceptable, so he got her in with another doc, who also had a good reputation. Unfortunately my mom had a bad outcome. Would it have been better had she been to the original doc? Maybe. But this wasn't an acute, life threatening problem and waiting a couple of weeks might have led to a better outcome, of course, it might not have either.

                I tend to be a therapeutic minimalist, and I like to deal with specialists who are very conservative and don't do things unless they are indicated. And I have attracted patients who have a similar mindset. People who want treatment now, right now, don't tend to stick around in my practice, but there are plenty of people in Baltimore who will accomodate them. Too many, probably.

                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 Jul 26, 2009 at 03:24:11 PM PDT

                [ Parent ]

                •  Believe me... (0+ / 0-)

                  as someone who has been through 3 major neurosurgeries...surgery sucks...so by all means it should be a last resort...and that is why when my condition started...the last person I spoke to was a surgeon...

                  Obama - Change I still believe in

                  by dvogel001 on Sun Jul 26, 2009 at 05:14:48 PM PDT

                  [ Parent ]

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