Gyroscopic Investing

It's almost as if it works!

http://www.tampabay.com/news/health/a-d ... ce/2262388

CLEARWATER — Dr. Trinette Moss runs her family practice a little differently than most physicians.

Instead of taking insurance, she prefers cash, check or credit card.

Billing at her office works like this: Patients between 18 and 49 years old pay $60 a month. The fee covers unlimited office visits, urgent care services and an annual physical. It costs $15 a month to add a child.

Moss says the model, known as direct primary care, makes financial sense. She doesn't have to hire anyone to file and track insurance claims. And she collects enough in monthly fees to keep her practice small.

"You know your patients better," she said. "You have more time to spend with them."

Moss isn't the only physician who likes the concept. Since Congress passed the Affordable Care Act in 2010, the number of practices like hers has jumped from about 20 to more than 400 nationwide, according to the Direct Primary Care Coalition.

I read the article and noticed that the doctor in the picture is an African American woman. Is it wrong to have worries that she might have become a doctor through affirmative action and may not be as qualified as other doctors? Does this make me a racist? WiseOne?

I only pay cash for medical care.

For people not already in bad shape, this is very easy.

Step 1. Avoid metabolic syndrome. This is the key to everything else. There are a lot of different opinions on how to do this, but basically it means, don't get fat and don't use carbs for fuel. This step is not a guarantee, but it is pretty damn close.

Next, I split medical care into several categories.

1) Trauma and Emergencies
Everything from stitches to falling off of a cliff to gallstones. Whether it means walking into a clinic or being life flighted to the trauma center, just pay up. If you are in really bad shape, just have the local folks patch you up enough to ship you to Bangkok where they understand cash.

2) Infection
Pay the clinic for a good diagnosis. Look up what drugs you need and buy them on line. Even two days of serious reading will make you smarter. Even better if you know someone who owns horses.

3) Chronic conditions.
See step 1. If you still have ongoing issues that diet and exercise wont fix, you are screwed. Drugs won't make your life better.

4) Senescence
Yea, we're all going to die at some point. I don't plan on drawing it out. When it becomes obvious that my time is limited, my risk tolerance will go way up until something gets me.

Reub wrote: I read the article and noticed that the doctor in the picture is an African American woman. Is it wrong to have worries that she might have become a doctor through affirmative action and may not be as qualified as other doctors? Does this make me a racist? WiseOne?

Why would you care either way about what a doctor with a small practice in Florida does?

Is there any evidence that this doctor is not qualified?  If not, why raise the race issue?

Do you have similar concerns about Ben Carson?  If not, why not?

IDrinkBloodLOL wrote:

Reub wrote: I read the article and noticed that the doctor in the picture is an African American woman. Is it wrong to have worries that she might have become a doctor through affirmative action and may not be as qualified as other doctors?

That's a perfectly legitimate worry.

Does this make me a racist?

Are you more worried about being called a racist than about dying of medical negligence?

The fact that the worry is considered legitimate by someone who is training to be a physician just illustrates how harmful affirmative action policies are when it comes to work where expertise really matters.

The people who are hurt most by all of this are, of course, the African American physicians who would be outstanding physicians with no preferential treatment at all.  These people spend their careers under an umbrella of suspicion about whether they got where they are through merit or through some kind of quota system.

When I was in law school, the school used a quota system where a certain number of spots were set aside for minority applicants, and the minority applicants only competed against one another.  In subsequent litigation, it was discovered that most of the minority students admitted under this program were FAR below the level of non-minority applicants.  In other words, most of the minority admissions were applicants who would have otherwise been nowhere near the level needed to gain admission.  In class, it was often very obvious who these students were, and it was also obvious which minority students would have been able to get in without any preferential treatment.

As a social experiment, what I am describing is just garden variety government and bureaucratic dumbassery.  The problem is that these marginal students get degrees from these prestigious schools and then go out into their communities and are hired by clients with real problems that need real solutions that require more than marginal skill levels in the professionals hired to do the work.

The people who are hurt are the customers and clients who put stock in what a degree from a prestigious school means, and, of course, the minority professionals who would have succeeded without any preferential treatment.

So I don't think Reub's point is one that doesn't deserve discussion if there is any issue about the quality of care being provided by a minority physician, but in the absence of any evidence that there is a quality of care issue, it seems like a needlessly inflammatory side note to the discussion of whether the way this physician runs her practice makes sense as a business model.

I'm another one of those cash-on-the-barrelhead types, and I detest the concierge model as much as I do the rest of the cost-shifting approaches.  For one who sees a general practitioner once a year at most, $60 a month makes for a darned expensive visit, especially when you consider how much gets referred on to specialists and the fact that you're still on the hook for any lab work or X-rays that might be involved.  As far as I can tell, the only "winners" in the concierge game are the ultra-high utilizers--a group, like any other, that I am loath to subsidize.

Oh, and as far as that "relationship" thing goes. . .  Couldn't we just chat at the baseball game?

MediumTex wrote:
When I was in law school, the school used a quota system where a certain number of spots were set aside for minority applicants, and the minority applicants only competed against one another.  In subsequent litigation, it was discovered that most of the minority students admitted under this program were FAR below the level of non-minority applicants.  In other words, most of the minority admissions were applicants who would have otherwise been nowhere near the level needed to gain admission.  In class, it was often very obvious who these students were, and it was also obvious which minority students would have been able to get in without any preferential treatment.

As a social experiment, what I am describing is just garden variety government and bureaucratic dumbassery.  The problem is that these marginal students get degrees from these prestigious schools and then go out into their communities and are hired by clients with real problems that need real solutions that require more than marginal skill levels in the professionals hired to do the work.

Ditto for engineering after the people were hired - early 1970's through 1980's.  The bright side was after about 10 to 15 years of "on the job training" reasonable competency emerged.  Lots of making sure a skilled co-workers were assigned with the less competent on projects in the interim.  All costs of increased manpower of course passed on to the unknowing customers.

... M

IDrinkBloodLOL wrote: To me, this shows why we shouldn't have diversity.

If we were all from the same racial group, such suspicions would be impossible.

Hitler? Is that you?

IDrinkBloodLOL wrote:

MediumTex wrote: The fact that the worry is considered legitimate by someone who is training to be a physician just illustrates how harmful affirmative action policies are when it comes to work where expertise really matters.

The people who are hurt most by all of this are, of course, the African American physicians who would be outstanding physicians with no preferential treatment at all.  These people spend their careers under an umbrella of suspicion about whether they got where they are through merit or through some kind of quota system.

To me, this shows why we shouldn't have diversity.

If we were all from the same racial group and there was no Other, such suspicions against the Other would be impossible. It's a simple, effective, time tested strategy for national stability and smooth function.

More topically:

One of the critiques of market-based medical care that I have seen is the fact that by nature a patient cannot know what services they will be purchasing or what the cost is, especially under any sort of emergency situation.

How would that work under free market conditions? Would I give physical exams, then a quote for what confirmatory tests I want to do, then another quote for treatments and such while they shop around looking for second opinions and better quotes?

Furthermore, how would these people be "informed consumers" when by default everything going on is beyond their scope and understanding it requires 12 years of education they just don't have and won't be getting?

I was under the impression that the professional/fiduciary arrangement between doctor/patient, lawyer/client and similar took for granted that they can't possibly hope to understand the details the way we do simply because it requires so much specific education, so we'll understand it for them and genuinely do what we can to make things go in their best interests.

That of course muddies the waters for the idea of an efficient marketplace. How can people create a truly efficient, fairly priced market for a product they don't understand and that requires a highly educated chaperone to utilize?

Fortunately this problem has in fact been solved rather effectively by private organizations without the need for government "help", in other cases of complex products that most people can't understand the details of.

I'll give you a hint: the initials of one such organization is "CR".

IDrinkBloodLOL wrote: To me, this shows why we shouldn't have diversity.

If we were all from the same racial group and there was no Other, such suspicions against the Other would be impossible. It's a simple, effective, time tested strategy for national stability and smooth function.

It's also too late; that ship has already sailed in the USA, unless you're prepared to in some way remove non-white legal citizens from civil society.

Which, come to think of it, is what the establishment has been trying to do to black people since emancipation.

Our "original sin" is our penchant for cheap labor. Under this influence, the original northern European American stock imported Africans, Italians, Irish, various eastern Europeans (part of my heritage) and most recently, hispanics. There seems to be something in our cultural DNA that says, "bring in foreigners who will work for less money than us!" Until and unless that's confronted, any dreams of a mono-racial society are utopian, and the longer it goes on, the more utopian they'll be.

I would hope that he meant diversity in the selection process and in hiring.

I always am leery when dealing with minorities in the medical field because I worry that they may be where they are not based on merit. Believe me, a bad doctor can kill you faster than any disease can.

I saw the same hiring practices in my 30 years at the FAA where minority trainees were brought in and certified because they were considered minorities, many times with horrendous results. Luckily most of these were quickly promoted to management so they were then able to continue the cycle.

This whole idea of racial homogeneity is odd, given that our country has been multi-cultural from early on, settled by immigrants from a variety of different countries, like Germany, Italy, Ireland, China, etc.

The difficulty of non-expert consumers being able to make informed choices is a real one, in many different areas.  It seems to me that we need to learn enough about a bunch of different specialties, like plumbing, electrical work, medicine, dentistry, etc. to be able to do that, and that's a drag.

I got a ridiculous span of recommended treatments from different dentists, ranging from "Your teeth are fine" to "You need $8,000 of work".

Simonjester wrote: well rounded humans are in short supply, part of being well rounded, and an informed consumer, is the ability to sort through and separate the good from the bad, to fill in the who what and where, to know a good sources from a bad ones and rate the quality/probability of informations truth and value. (the first step in the three pillars of critical thinking) if you can think critically, buying complex services is not that big a challenge, and certainly not the great mystery that those protecting their turf might present it as being...
It doesn't matter what is being sold, complex medical procedures or sugar cereal, the seller and consumption based capitalism in general, benefits from a large consumer base of uninformed buyers... that plus the benefit to politicians selling their brand of BS with greater ease, its no wonder critical thinking is not being pushed anywhere outside the occasional home school....

BearBones wrote:

IDrinkBloodLOL wrote: To me, this shows why we shouldn't have diversity.

If we were all from the same racial group, such suspicions would be impossible.

Hitler? Is that you?

I think there is something in our cultural DNA that always seems to cause any large group to fracture into us/them in times of stress.

Think of all of the societies that to us look utterly homogeneous, but when the society experiences stress all of the sudden you see the following types of divisions:

Shiite vs. Sunni
Catholic vs. Protestant
Rich vs. Poor
Old vs. Young
Progressive vs. Traditional
Old Natives vs. More Recent Arrivals
Educated vs. Ignorant
Yankees vs. Mets

Look at all of the wars among Native American tribes.  Those people as a group were quite homogeneous, and yet they fought with one another constantly.

Every complex society is going to have "diversity."  One current example is Iraq, where I couldn't possibly pick which Iraqis in a crowd were Sunni, Shiite or Kurd, but these distinctions can easily get you killed in that society.

Just thought I'd weigh in...

re the minority issue:  unfortunately, the effect of "diversity" metrics is indeed that you can get minorities in the field with subpar skills.  And yes, it does a disservice to those who deserve their job positions.  I've seen examples of both.

re concierge care:  it's not a bad model.  The overhead of an insurance-funded practice is astronomical:

- billing service, service denials; these reduce collections to about 30% of what is billed
- cost of an approved electronic health record system
- responding to insurance denials, requests for preauthorizations etc
- staying credentialed with each of a handful of local insurers, plus Medicare/Medicaid
- meeting Medicare documentation & coding requirements


It would be better yet, though, for physicians just to scrap all of the above and charge cash for visits.  If they're worried about people who need a lot of attention getting stiffed, they could set a reduced cost for followup visit less than 3 months, say.  The resulting competition & ability for people to comparison shop would be tremendous.

WiseOne wrote: It would be better yet, though, for physicians just to scrap all of the above and charge cash for visits.

In your opinion, why don't they?

I'll take a stab at that.

First, if you don't take Medicare, you lose a lot of potential patients.  Then, most people who have insurance don't want to pay for insurance and then also a "concierge" doctor or actual costs of medical care.

The Surgical Center of Oklahoma is an example of an institution that has gone to an all-cash model.  http://surgerycenterok.com/  It posts its prices up front and expects cash at the time of service.  Not surprisingly, its prices are a mere fraction of what's being charged for similar procedures elsewhere. One of its docs, Keith Smith, M.D., (an orthopedic surgeon, I believe) has a blog which is an interesting read.  http://surgerycenterofoklahoma.tumblr.c ... al-records . 

Pointedstick wrote:

WiseOne wrote: It would be better yet, though, for physicians just to scrap all of the above and charge cash for visits.

In your opinion, why don't they?

The all-cash model effectively shuts down the cost-shifting game.  That means losing the ability to do great works of altruism on somebody else's dime.  Price transparency means losing the ability to take massive write-offs of purely fictional losses.

Pointedstick wrote:

WiseOne wrote: It would be better yet, though, for physicians just to scrap all of the above and charge cash for visits.

In your opinion, why don't they?

Good question.  I really don't know for sure.  It might be that the subscription-based system offers a steady income and makes it easier to plan.  Honestly I have not much idea here since I am embedded in a university practice that wouldn't dream of going to a cash system, and I know exactly one physician who went to cash.  He opted for a concierge service.  In his case, though, I think he chose the option that made his life easiest, and let him concentrate on taking care of his patients (he's the kind of MD who gives his cell phone # to his patients, and covers all his own calls). 

WiseOne wrote: Honestly I have not much idea here since I am embedded in a university practice that wouldn't dream of going to a cash system,

Why wouldn't they?

The concierge practices I've seen usually recommend that patients have insurance, at least to cover large unexpected expenses, in addition to a monthly/annual charge for the practice.

Pointedstick wrote:

WiseOne wrote: Honestly I have not much idea here since I am embedded in a university practice that wouldn't dream of going to a cash system,

Why wouldn't they?

I would say to a large degree the growth of medical providers who provide cosmetic procedures typically not covered by insurance means that doctors HAVE gone to a cash only business model in many cases.

I would imagine that one of the draws to doing boob jobs, tummy tucks, and facelifts is that you are mostly out of the insurance reimbursement game.

MangoMan wrote: You guys are over thinking this. In order to be successful in a concierge practice model, you have to get X number of patients to agree to cough up the annual membership fee and forego traditional insurance. Not many people are willing to do this. The reimbursement model is surprisingly close to HMOs. You can only make it work financially if you have lots of subscribers. Ask me how in know. 

The concierge models I've seen so far seems stupid.  Its paying cash for stupid shit like getting a physical, a prescription, a useless vaccine, etc. you know the kind of time wasting basic care for the hypochondriacs.  Anything significant like labs, x-rays, etc. isn't covered and costs extra and if you don't have insurance, you da,m we;; better figure out how to get cash discount.  So you're paying a few thousand a year for essentially security theatre, not anything hard core useful.