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D1984
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Re: Gold's Time To Shine?

Post by D1984 » Sun Feb 16, 2020 10:34 am

MangoMan wrote:
Sun Feb 16, 2020 8:31 am
D1984 wrote:
Sun Feb 16, 2020 3:40 am



AFAIK you can do that in Canada too. Canada doesn't fully ban full price up front in cash-on-the-barrelhead private medical practice; it bans private health INSURANCE. Physicians (whether singly or in group practice), surgicenters, clinics, imaging centers, etc can opt out of the public payment system (their province's Medicare system) but in doing so they forfeit the right to bill Medicare for ANYTHING for a certain period; also, in some provinces (Ontario does this and I presume at least some of the other provinces do as well) physicians who opt out of Medicare and bill patients privately for cash cannot charge said patients above the agreed-upon provincial Medicare fee schedule anyway unless they are treating non-insured persons (i.e. persons for whom Medicare would not be the first-line payer...stuff like workmen's comp cases, auto accident victims, persons who are not Canadian citizens or PRs, etc).

Again, as far as I know both the Single Payer bill by Bernie and the one by Jayapal do similarly as above in allowing cash-only medicine but prohibiting providers from billing Medicare for a set period (IIRC it is 3 years) should they choose to be cash-only/prepaid/concierge practices.
::) ::) ::)
This defeats the whole purpose and incentive for opting out as a provider (capitlism!). If you can't charge more for delivering a better (or, in this case, more timely) service, you may as well stay in the system for the increased volume. The only reason the concierge model works here is because of supply and demand coupled with un restrictive pricing.
I guess if you asked Ontario's Minister for Health he/she would say that was the whole point; they want to avoid as much as feasible a two-tiered system and by keeping as many doctors practicing in the public system as possible (and incentivizing as few of them as possible into cash-only practices) this helps to ensure that the vast majority of the wealthy use the same system everyone else does and thus have an incentive to want to see it working well just like the poor and middle class do.

Most countries with universal healthcare don't regulate what cash-only doctors can charge but EVERY country with universal healthcare does directly or indirectly regulate what providers can charge those insured under the system (whether that system is socialized medicine a la the NHS, single-payer like in Canada, single-payer with additional optional private insurance for stuff the public system doesn't fully cover like France, single-payer but with the ability for those who can afford and wish to to buy a private insurance policy and totally bypass the public system like Australia, government-funded hospitals, government catastrophic insurance and private health savings accounts like in Singapore, or a mandatory private but not-for-profit system like Switzerland where you are required/mandated to buy insurance--and subsidized if you are too poor--but can choose from a variety of not-for-profit private insurers and switch if you are unsatisfied); we alone in America do not have universal healthcare and don't do any kind of nationwide or statewide regulation of what providers can charge and thus we get ripped off by some of the highest prices for medical care in the world....see the IFHP reports if you don't believe this.
We already basically have socialized medicine here in the US in most cities, it just looks different. If you practice here in Chicago in a non-concierge practice, you are limited to charging the fees set by insurance contracts or medicare since almost all of your patients have one or the other, and if you don't participate in the PPOs, you won't have any patients at all as they will just go to the guy 2 doors down who is in-network. And the premiums of the wealthier people help pay for those receiving subsidies. Voila: defacto socialized medicine.
If a doctor doesn't like the prices the private insurance companies offer and doesn't like what Medicare offers either he/she can just run a cash-only practice. They would likely have plenty of cash-only patients if they charged, say, from $11 to $45 for an office visit--which is the range of prices for an office visit (not copayments...actual prices in full...and this is to see a regular GP, not an NP or a PA) in other countries (again, as per the IFHP reports...granted, this is from the 2013 and 2010 reports--they issue a report every few years but not every report includes the cost of a routine office visit--so prices may be a little higher in other countries since then due to inflation....but I'd be willing to bet US prices rose just as fast if not faster). And yes, I know that to do this (have doctors charge such low prices for a basic GP office visit) we would have to be more like other countries and revamp our whole education system and have heavily subsidized (or free) college and medical education so that doctors didn't graduate med school with a $260K (or more) millstone around their necks that makes them see the need for much higher salaries than in other countries and we'd also have to start paying them decent wages during internship/residency rather than 45K or so a year (and while we're at it, also stop working them so many crazy excessive hours during said internship/residency which means we'd need to lift the Medicare MCE cap and fund training of several thousands or tens of thousands of doctors more each year so we'd actually have enough docs without overworking/burning out the ones we have during the immediate postgrad training like we do now)...all of which I'd be fine with BTW; it would cost more upfront but it would likely save money over the long term.

We don't have de facto socialized medicine; socialized medicine is when the government runs the hospitals/clinics directly and the doctors/nurses are all salaried government employees. We do have a system of quasi-price regulation by insurance companies and Medicare but Medicare cannot negotiate as low of prices as the universal systems in other countries because it is not the monopsony buyer--since it does not cover everyone but only covers the elderly and those with ESRD-- and because since private insurance exists as well (private insurance exists in plenty of other countries too but in all of those countries private insurers negotiate with providers on a nationwide/provincewide/cantonwide basis and so have some serious negotiating clout owing to the fact that in such a situation these private insurers are negotiating all as one and are thus a quasi-monopsony buyer as well) so if Medicare offers too little in the eyes of providers they can just say no and refuse Medicare and only take privately insured patients; private insurers have little/no negotiating clout here in the US because there are typically ten (or more) of them competing whereas in many/most areas providers are effectively a monopoly or an oligopoly and so the providers (hospitals/doctors/drug companies/medical device makers) can name their price and the private insurer has little choice but to take it.

If we had universal Medicare for all (or at least all-payer rate setting where all the private insurers + Medicare + Medicaid negotiated prices all as one on a national or regional basis and thus functioned as a monopsony buyer de facto even if not de jure) then the power would be back in the buyer's lap and medical prices would likely come down to be somewhat closer to the prices in the rest of the OECD countries. We don't so we get stuck with some of the highest healthcare prices in the developed world.
Last edited by D1984 on Sun Feb 16, 2020 12:17 pm, edited 1 time in total.
WiseOne
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Re: Gold's Time To Shine?

Post by WiseOne » Sun Feb 16, 2020 11:40 am

MangoMan wrote:
Sun Feb 16, 2020 8:31 am
D1984 wrote:
Sun Feb 16, 2020 3:40 am



AFAIK you can do that in Canada too. Canada doesn't fully ban full price up front in cash-on-the-barrelhead private medical practice; it bans private health INSURANCE. Physicians (whether singly or in group practice), surgicenters, clinics, imaging centers, etc can opt out of the public payment system (their province's Medicare system) but in doing so they forfeit the right to bill Medicare for ANYTHING for a certain period; also, in some provinces (Ontario does this and I presume at least some of the other provinces do as well) physicians who opt out of Medicare and bill patients privately for cash cannot charge said patients above the agreed-upon provincial Medicare fee schedule anyway unless they are treating non-insured persons (i.e. persons for whom Medicare would not be the first-line payer...stuff like workmen's comp cases, auto accident victims, persons who are not Canadian citizens or PRs, etc).

Again, as far as I know both the Single Payer bill by Bernie and the one by Jayapal do similarly as above in allowing cash-only medicine but prohibiting providers from billing Medicare for a set period (IIRC it is 3 years) should they choose to be cash-only/prepaid/concierge practices.
::) ::) ::)
This defeats the whole purpose and incentive for opting out as a provider (capitlism!). If you can't charge more for delivering a better (or, in this case, more timely) service, you may as well stay in the system for the increased volume. The only reason the concierge model works here is because of supply and demand coupled with un restrictive pricing.

We already basically have socialized medicine here in the US in most cities, it just looks different. If you practice here in Chicago in a non-concierge practice, you are limited to charging the fees set by insurance contracts or medicare since almost all of your patients have one or the other, and if you don't participate in the PPOs, you won't have any patients at all as they will just go to the guy 2 doors down who is in-network. And the premiums of the wealthier people help pay for those receiving subsidies. Voila: defacto sociailzed medicine.
Actually, Medicare isn't the source of delayed treatment in the American system. It's the private insurers that play the preauthorization game that results in delays and denials. Yet another reason to avoid Medicare Advantage plans like the plague.

I agree that an insurance model that covers routine, low-level expenses is idiotic and makes about as much sense as, say, getting haircut insurance, but I'm resigned to that being fixed in stone. If you accept that, then a Medicare for all system may in fact be our best solution. I wish medical insurance could work more like it does in veterinary medicine, where the added costs of a full coverage insurance policy for a pet are necessarily greater than what you'd spend for the routine care that it covers - so those policies basically amount to a stupidity tax. Also, because insurance isn't nearly so intrusive in the pet world (minimal documentation requirements, no preauths), office visit costs are a lot lower. Gives you an idea of what they would be in the human world without that added layer of insanity.
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Re: Gold's Time To Shine?

Post by Libertarian666 » Sun Feb 16, 2020 3:06 pm

WiseOne wrote:
Sun Feb 16, 2020 11:40 am
MangoMan wrote:
Sun Feb 16, 2020 8:31 am
D1984 wrote:
Sun Feb 16, 2020 3:40 am



AFAIK you can do that in Canada too. Canada doesn't fully ban full price up front in cash-on-the-barrelhead private medical practice; it bans private health INSURANCE. Physicians (whether singly or in group practice), surgicenters, clinics, imaging centers, etc can opt out of the public payment system (their province's Medicare system) but in doing so they forfeit the right to bill Medicare for ANYTHING for a certain period; also, in some provinces (Ontario does this and I presume at least some of the other provinces do as well) physicians who opt out of Medicare and bill patients privately for cash cannot charge said patients above the agreed-upon provincial Medicare fee schedule anyway unless they are treating non-insured persons (i.e. persons for whom Medicare would not be the first-line payer...stuff like workmen's comp cases, auto accident victims, persons who are not Canadian citizens or PRs, etc).

Again, as far as I know both the Single Payer bill by Bernie and the one by Jayapal do similarly as above in allowing cash-only medicine but prohibiting providers from billing Medicare for a set period (IIRC it is 3 years) should they choose to be cash-only/prepaid/concierge practices.
::) ::) ::)
This defeats the whole purpose and incentive for opting out as a provider (capitlism!). If you can't charge more for delivering a better (or, in this case, more timely) service, you may as well stay in the system for the increased volume. The only reason the concierge model works here is because of supply and demand coupled with un restrictive pricing.

We already basically have socialized medicine here in the US in most cities, it just looks different. If you practice here in Chicago in a non-concierge practice, you are limited to charging the fees set by insurance contracts or medicare since almost all of your patients have one or the other, and if you don't participate in the PPOs, you won't have any patients at all as they will just go to the guy 2 doors down who is in-network. And the premiums of the wealthier people help pay for those receiving subsidies. Voila: defacto sociailzed medicine.
Actually, Medicare isn't the source of delayed treatment in the American system. It's the private insurers that play the preauthorization game that results in delays and denials. Yet another reason to avoid Medicare Advantage plans like the plague.

I agree that an insurance model that covers routine, low-level expenses is idiotic and makes about as much sense as, say, getting haircut insurance, but I'm resigned to that being fixed in stone. If you accept that, then a Medicare for all system may in fact be our best solution. I wish medical insurance could work more like it does in veterinary medicine, where the added costs of a full coverage insurance policy for a pet are necessarily greater than what you'd spend for the routine care that it covers - so those policies basically amount to a stupidity tax. Also, because insurance isn't nearly so intrusive in the pet world (minimal documentation requirements, no preauths), office visit costs are a lot lower. Gives you an idea of what they would be in the human world without that added layer of insanity.
So let me see if I understand this.
The current "Medicare for some" (mostly over 65 with a few others) is completely and utterly bankrupt, having unfunded liabilities in the tens of trillions of dollars (see https://www.marketwatch.com/story/the-f ... 2018-06-15).
Therefore expanding it to five times its current size is a good idea.
Is that right?
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Re: Gold's Time To Shine?

Post by D1984 » Sun Feb 16, 2020 4:05 pm

Libertarian666 wrote:
Sun Feb 16, 2020 3:06 pm
WiseOne wrote:
Sun Feb 16, 2020 11:40 am
MangoMan wrote:
Sun Feb 16, 2020 8:31 am
D1984 wrote:
Sun Feb 16, 2020 3:40 am



AFAIK you can do that in Canada too. Canada doesn't fully ban full price up front in cash-on-the-barrelhead private medical practice; it bans private health INSURANCE. Physicians (whether singly or in group practice), surgicenters, clinics, imaging centers, etc can opt out of the public payment system (their province's Medicare system) but in doing so they forfeit the right to bill Medicare for ANYTHING for a certain period; also, in some provinces (Ontario does this and I presume at least some of the other provinces do as well) physicians who opt out of Medicare and bill patients privately for cash cannot charge said patients above the agreed-upon provincial Medicare fee schedule anyway unless they are treating non-insured persons (i.e. persons for whom Medicare would not be the first-line payer...stuff like workmen's comp cases, auto accident victims, persons who are not Canadian citizens or PRs, etc).

Again, as far as I know both the Single Payer bill by Bernie and the one by Jayapal do similarly as above in allowing cash-only medicine but prohibiting providers from billing Medicare for a set period (IIRC it is 3 years) should they choose to be cash-only/prepaid/concierge practices.
::) ::) ::)
This defeats the whole purpose and incentive for opting out as a provider (capitlism!). If you can't charge more for delivering a better (or, in this case, more timely) service, you may as well stay in the system for the increased volume. The only reason the concierge model works here is because of supply and demand coupled with un restrictive pricing.

We already basically have socialized medicine here in the US in most cities, it just looks different. If you practice here in Chicago in a non-concierge practice, you are limited to charging the fees set by insurance contracts or medicare since almost all of your patients have one or the other, and if you don't participate in the PPOs, you won't have any patients at all as they will just go to the guy 2 doors down who is in-network. And the premiums of the wealthier people help pay for those receiving subsidies. Voila: defacto sociailzed medicine.
Actually, Medicare isn't the source of delayed treatment in the American system. It's the private insurers that play the preauthorization game that results in delays and denials. Yet another reason to avoid Medicare Advantage plans like the plague.

I agree that an insurance model that covers routine, low-level expenses is idiotic and makes about as much sense as, say, getting haircut insurance, but I'm resigned to that being fixed in stone. If you accept that, then a Medicare for all system may in fact be our best solution. I wish medical insurance could work more like it does in veterinary medicine, where the added costs of a full coverage insurance policy for a pet are necessarily greater than what you'd spend for the routine care that it covers - so those policies basically amount to a stupidity tax. Also, because insurance isn't nearly so intrusive in the pet world (minimal documentation requirements, no preauths), office visit costs are a lot lower. Gives you an idea of what they would be in the human world without that added layer of insanity.
So let me see if I understand this.
The current "Medicare for some" (mostly over 65 with a few others) is completely and utterly bankrupt, having unfunded liabilities in the tens of trillions of dollars (see https://www.marketwatch.com/story/the-f ... 2018-06-15).
Therefore expanding it to five times its current size is a good idea.
Is that right?
Medicare's unfunded liability over a 75 year period (the next 75 years) is $37 trillion as per the article. Well....that sounds scary. Actually, that is only around 2.27% of GDP per year. That doesn't sound quite as scary, does it? Think tanks that publish articles like this use the 75 year or 100 year or even (if the Trustees are still making it as of 2020; I thought they quit making that one for SS and Medicare back in the mid-2000s) the "infinite horizon" period in order to scare people. In actually it is likely even less than 2.27% of GDP per year since I derived that figure using today's GDP (and assuming per capita GDP will never grow in real terms since then....i.e. it will grow with inflation but total GDP will never grow beyond inflation and population growth i.e. I assumed ZERO productivity growth which I think we can agree is just a wee bit unrealistic), dividing $37 trillion by 75, and dividing that number by today's GDP (which again, I assumed no real increase whatsoever in except for via population growth and inflation) and projecting today's GDP out 75 years. Finally, most of the unfunded liabilities are going to occur in later years (the Trust Funds don't even start running a deficit until the mid to late 2020s) so given the time value of money it would be even less in terms of a % of GDP if we had to raise taxes enough immediately to fund it since we would be building up extra money in the trust funds staring from right now--and it would be earning interest--for at least the next several years before we spent even one extra cent out of the revenue the new taxes would generate.

Also, if you calculated private insurance companies' liabilities the same way they calculated Medicare's liabilities (IIRC the Trustees--likely quite correctly--assume costs will increase in line with the aging of the population and assume medical cost inflation will continue to outpace regular inflation) and calculated said insurance companies' income to service those liabilities by assuming premiums were never allowed to increase other than through inflation, population growth, and GDP per worker output growth (when calculating unfunded liabilities the Trustees AFAIK are assuming current tax rates and no increase in FICA or income taxes at all; the total amount of taxes can grow with more people or inflation or real output/GDP growth but tax rates themselves are assumed to stay at whatever current rates are) and that if insurance payouts for medical care increased faster than said premiums well then...too bad, too sad...you still won't be allowed premium increases enough to offset this....I'd bet that you'd come up with a pretty hefty "unfunded liability" estimate for private insurance as well. Needless to say private insurance companies do not have this problem because they can increase premiums as needed in order to stay solvent; Medicare has to rely on Congress and the White House OKing tax increases; it can't just increase its own funding stream (taxes) with the ease which insurance companies can increase their funding stream (by hiking premiums).

The problem that creates such a huge "unfunded liability" in either case is that medical costs keep increasing faster than inflation and usually they even increase faster than inflation plus real GDP per capita growth. FWIW Medicare seems to be better at controlling costs per beneficiary than private insurance; see https://www.modernhealthcare.com/articl ... study-says ; presumably this is because it has more bargaining power than private insurers.

EDIT - given that the Trustees projected the present value of Medicare's "unfunded liabilities" was $37 trillion then perhaps they should've contextualized that by comparing it to the present value of all GDP over that same 75-year period. Back in late 2010 the projected present value of 75 years worth of GDP (what you would have to pay now to receive the discounted value of 75 years worth of GDP paid to you) was $791 trillion ( https://seekingalpha.com/article/207272 ... iabilities ). Given that real inflation-adjusted GDP has increased around 23 percent or so since then we can presume the 75 year discounted present value of all the GDP for that timeframe (for the next 75 years starting today rather than starting in late 2010) has increased as well. That would put said value at around $972 trillion (give or take a trillion $ either way); $37 trillion is a bit over 3.78% of that. Not exactly insurmountable.
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Re: Health insurance

Post by Libertarian666 » Sun Feb 16, 2020 5:23 pm

Lol!
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Re: Health insurance

Post by Don » Sun Feb 16, 2020 5:40 pm

I know an illegal immigrant who suffered a massive heart attack in NYC. He was revived and spent 2 weeks in a fine hospital. After about a month he went back in for another week for a heart valve repair.

His bill is probably close to a million dollars but it's not costing him a cent.

How can this country not go bankrupt absorbing these huge health bills from illegals?
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Re: Health insurance

Post by blackomen » Sun Feb 16, 2020 6:12 pm

Don wrote:
Sun Feb 16, 2020 5:40 pm
I know an illegal immigrant who suffered a massive heart attack in NYC. He was revived and spent 2 weeks in a fine hospital. After about a month he went back in for another week for a heart valve repair.

His bill is probably close to a million dollars but it's not costing him a cent.

How can this country not go bankrupt absorbing these huge health bills from illegals?
We need to send that bill to Mexico or whatever his home country is.
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Re: Health insurance

Post by Libertarian666 » Sun Feb 16, 2020 8:26 pm

Don wrote:
Sun Feb 16, 2020 5:40 pm
I know an illegal immigrant who suffered a massive heart attack in NYC. He was revived and spent 2 weeks in a fine hospital. After about a month he went back in for another week for a heart valve repair.

His bill is probably close to a million dollars but it's not costing him a cent.

How can this country not go bankrupt absorbing these huge health bills from illegals?
Isn't that question racist?
(Note: sarcasm)
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Re: Health insurance

Post by WiseOne » Mon Feb 17, 2020 8:48 am

blackomen wrote:
Sun Feb 16, 2020 6:12 pm
Don wrote:
Sun Feb 16, 2020 5:40 pm
I know an illegal immigrant who suffered a massive heart attack in NYC. He was revived and spent 2 weeks in a fine hospital. After about a month he went back in for another week for a heart valve repair.

His bill is probably close to a million dollars but it's not costing him a cent.

How can this country not go bankrupt absorbing these huge health bills from illegals?
We need to send that bill to Mexico or whatever his home country is.
Now there's an idea!

To be fair, if you travel, say, to the UK on a visit and have that same heart attack scenario, you'd receive your emergency care for free. The problem here in the US is the sheer numbers of illegal immigrants who end up needing emergency services. It is a substantial drain on the US hospital system, and a big reason why your costs are higher than they would be in a country with a more sane immigration policy.

D1984 that is a most excellent analysis, thanks! I should point out though that a large cost savings would also result from scrapping the ridiculous burdensome regulations that Obama put in place, and simplifying the byzantine documentation and billing rules that Medicare implemented long ago, I think under Clinton. Those rules were adopted by private insurers, so Medicare leads the way on these things and could force a change throughout the entire system. Medicare actually tried to do this a year ago, and the AMA pushed back on it and forced them to back down. I will not readily forgive the AMA for that.

Something also needs to be done about the EHR disaster. Not only is it driving up costs, it is forcing many older physicians (and some younger ones who just can't take the b-s anymore) out of the profession. And the ones still here spend something like 3/4 of their time on documentation tasks that used to be maybe 10% of time - do the math on that one. I think it would be hard at this point for institutions to get rid of their EHRs and go back to paper, so I'm not really sure what can be done. The golden opportunity was missed when the Obama administration mandated EHRs but did not declare CPRS/Vista as the national EHR system. (Yes there's another irony for you...CPRS was developed by the VA system, and it's far more user friendly, efficient and functional than any of the private EHRs - which were designed by and for lawyers and billers). I don't know a single physician who wouldn't cheer mightily if CPRS/Vista became their new EHR.
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Re: Health insurance

Post by Kbg » Mon Feb 17, 2020 11:11 am

Am I wrong on this...to me since entering the commercial medical system it’s all about wringing the procedure bell as many times as legitimately possible for a given medical issue.
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Re: Health insurance

Post by boglerdude » Mon Feb 17, 2020 10:54 pm

> How can this country not go bankrupt absorbing these huge health bills from illegals?

Depends how much wealth he generates. Because he's illegal we can pay him less than minimum wage, so he might generate more net revenue than many citizens
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Re: Health insurance

Post by WiseOne » Tue Feb 18, 2020 8:13 am

Kbg wrote:
Mon Feb 17, 2020 11:11 am
Am I wrong on this...to me since entering the commercial medical system it’s all about wringing the procedure bell as many times as legitimately possible for a given medical issue.
Oh absolutely. Going to a physician, especially a specialist who does procedures, is increasingly putting yourself into the hands of a used car salesman. The physician may well be competent and caring, but he/she is also motivated - and pressured from above - to maximize billing.

The pressure from above, by the way, is now the main driver of that. The main effect of Obama's presidency was to put in place a vastly increased layer of administrators, all of whom want to be paid handsomely for their role in cracking the whip on us peons (oh excuse me, physicians).
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Re: Health insurance

Post by Kriegsspiel » Tue Feb 18, 2020 9:37 am

A physical therapist I was working with for a bit told me that his overseers were doing the same thing to him.
You there, Ephialtes. May you live forever.
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