Saturday, June 3, 2017

Unagidon is Back!!

Up at Commonweal:

"A great president once said, “Nobody knew that health care could be so complicated.” Put aside the fact that absolutely everyone knew except him, the statement is pretty good if you change it to: “nobody knew how health care is so complicated.”

34 comments:

  1. Thanks for the heads-up, Margaret! Always glad to see Unigidon's articles.

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  2. Reading Unagidon's on "how" medical care is priced (not the free market!) makes me realize that Obamacare was a miracle of squaring multiple circles (or as U says...2000 pages).

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    1. No wonder the Republicans are at a loss!

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  3. Great article by Unagidon. One thing I never understand about the health care insurance problem ... if almost every other country is able to offer universal health care, why can't we just copy one of those plans, since it's obviously do-able?

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    1. We copied Romneycare, which worked in Mass., thinking the GOP would go along with a GOP inspired plan. Romney then said it wasn't really his plan and that it wouldn't work on a national scale. The main objections to the ACA seems to be that there's not enough "free market" involvement and that it's expensive.

      I continue to be concerned about the expense of the program, though some of that is tempered by looking at where we waste money.

      I wish Unagidon had 30 minutes alone with President Trump to explain some of these issues.

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    2. Trump's attention span is five minutes, so the other 25 would be wasted. The sources for the five minutes are his supporters, not people like me.

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    3. We can't just copy someone else because of the way the money flows in our system. The cash flows between who pays and who receives would have to be backed out of. For example, on the cash in side, there are all of the businesses that pay for insurance for their employees. Anything we do in the system is going to have to capture these dollars. But how? Do we institute a new tax on corporations. Do we institute a new tax on the public and either require businesses to take the old premium dollars they used to spend on insurance and give it to the workers as a direct payment to cover the new tax? On the payment side, providers are now subsidized by private insurance for the shortfalls they have on the Medicare/Medicaid side. A simple transfer to Medicare for all would eliminate this subsidy. So how do we make them whole? Or should we? Stuff like this. One has to go from what we have to what we want. Since no European or Asian system started out looking like the abomination that ours it, they don't really offer any help for us as a model of how to proceed, as much as they might look like a good model of what to get to.

      And for what it's worth, I wouldn't start with Trump anyway. I'd start in the Senate.

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  4. Unagidon writes:

    "Not getting primary care means that their cancers and such will be missed until they get sick enough to have to go to the emergency room. And the fact that they can’t get care for chronic illnesses means they’ll be coming back, far sicker than they need to be, over and over again until they die. And you, the insured, get to pay for this."

    Yes. It's important to note that the chronically I'll really don't receive care at the ER. The ER will attempt to stabilize you and send you home.

    Hospice care for the chronically as well as terminally ill seems to be an idea that is gaining traction. There is absolutely nothing about my cancer that a nurse couldn't handle on a monthly (or once every three months)basis following protocols by the hematologist: Check blood counts, check extremities for blood clots, adjust chemo dose, make diet and exercise suggestions, handle chemo side effects, and ensure blood pressure is OK.

    We are very low maintenance patients and can remain that way for years.

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    1. Hospice care for the chronically as well as terminally ill seems to be an idea that is gaining traction.

      Yeah, I think this is really the Republican version of 'let them die in the streets'.

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    2. Why do you think that? My dad's quality of life improved on hospice. Hospice comes to you, reduces the burden of monitoring, helps with occupational therapy, etc. There's no cure for my type of cancer, I have no inclination to participate in clinical trials, and I would prefer a hospice approach. It would be nice to have that choice.

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    3. Maybe I don't understand what hospice care is. I've never known anyone who has used it. I thought it was just where people went to die, with pain meds?

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    4. Crystal, a succession of our friends died in Hospice care. After watching how they went, we paid an extra $80 a year to have a Hospice license plate on our car. (The extra supports Hospice.) And my wife is cheap.

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    5. Hospice is associated with the terminally ill. But broadly speaking, it is maintenance care, and the role of hospice could extend to managing a chronic disease like diabetes or COPD or CHF by visiting the patient at home and offering info and encouragement on meds, diet, and exercise. Hospice can also provide occupational therapy and discuss home modifications that make your life easier. Hospice nurses can also put patients in touch with agencies and volunteers that can provide needed services.

      Hospice is really more a philosophy of care than a physical place.

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    6. Though hospice can mean a physical place. Some hospitals, especially in small towns, and some nursing homes as well, have hospice beds. Sometimes families cope at home as long as they can, but get overwhelmed at the last. My mother spent her last several days in a hospice room at the hospital. By that time she was unconscious. Family members kept watch with her there.

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    8. I agree that hospice is more a philosophy than a place, there are also some rules that distinguish it from nursing home care.

      My father was in a hospice run by a hospital for the last few days of his life. When I signed the form for hospice care, they informed me that as long as dad continue to deteriorate or need the care he was getting in the hospital (he had been admitted), Medicare would pay the residential fee as well as the treatment just as in a hospital. However if dad improved then I would be responsible for the residential fee but Medicare would continue to pay for the treatment. I probably had the option to take him home and have hospice care there.

      The hospice was brand new, less than six months old, a very beautiful place. While a lot of the people that came there stayed for only a short time before death, they built it to be very family friendly with beautiful rooms and a place to cook in case people needed it for a long time. It was like a home away from home, actually a very fine looking home.

      It was light years away from a hospital, or nursing home, and it was certainly better than trying to keep dad at home. He was getting beyond my ability to manage; I had to ask his sister to stay overnight so that we could take turns sleeping.

      When you think you'll need this service it is good to check out of the options well ahead of time. I should probably have had dad there two or three weeks earlier. Dad's doctor was no help. When I asked him what do I do if I can't take care of dad, he simply said take him to the hospital. Fortunately I began to look around and had actually scheduled a visit to the hospice but then dad had to be taken to the hospital

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    9. Thanks, you guys. I had no idea there was that much to it.

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  5. "Hospice care for the chronically as well as terminally ill seems to be an idea that is gaining traction."

    Health care for the chronically ill needs to be more like the mental health system in which a lot of care is in the hands of social workers, case managers, and nurses rather than in the hands of physicians (who are mainly concerned with medication management.

    When I developed a balance problem about five years ago, I was in a Medicare Advantage plan which limited my physical therapy to six visits a year; it took me three years to get the physical therapy to restore my ability to do aerobic exercise. IN the meantime a bunch of other problems developed, which in the end of things were solved when I was able to resume aerobic exercise sufficiently. The advantage plan was penny wise but pound foolish.

    My primary physician agreed with me when I said the best plan for me (I have a lot of spinal deterioration) would be to see a physical therapist one a month for the rest of my life to keep checking out my functioning, my ability to do various exercises and spend some time practicing an old or new one. It would probably be the most cost effective and give me the best quality of life in the long run.

    The problem with the present system for chronic problems is that one spends a lot of time with specialists who give expensive tests, and expensive solutions. For example I was told I had sleep apnea. After I lost the 15 pounds that I had gained when I was not able to exercise sufficiently, they retested me and told me I did not have sleep apnea anymore. Being a scientist, I figured out the first test was done on a normal flat bed, the second on a hospital reclining bed. I bought an adjustable bed and a $5 app for my iPhone. Sure enough I snore solidly when the bed is flat, and rarely snore when it is adjusted at the right angle. Lots of wasted money and time trying to use that CPAP machine. Why don't they require that all sleep apnea tests be done on adjustable beds? I guess the adjustable bed companies don't have as much political clout as the CPAP companies and the doctors.

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    1. Jack, glad you are doing better now. I follow Medicare issues with interest to try and figure out whether we should go with Advantage or traditional Medicare once I retire and lose my work insurance. It's looking like traditional Medicare is what we will do.
      About the sleep apnea, I know some people don't like the CPAPs but my husband does well with his. I am grateful for it because I was just about ready to move into the guest room because of the snoring.

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    2. I had Medicare Advantage only because the Public Employees Retirement System chose that plan, it was specially tailored to them; I am now on traditional Medicare. PERS now gives us a voucher to choose what we want; for most retires that is traditional; I chose AARP because it is community rated rather than age rated, and it has Silver Sneakers which lets me use a variety of local fitness centers.

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    3. I have traditional Medicare and I think that's best, at least for me. The down side is that it doesn't pay for everything, but still I think you have more choices about care when you aren't within an HMO kind of thing.

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  6. Is anyone else having trouble with their comments posting twice? I have had to delete several of mine that were duplicates. Don't know why that happens.

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    1. Don't know. I delete mine when I find mistakes. There can never be too much proofreading before hitting the "Publish" button. Didn't the beloved dotCommonweal allow commenters to go back and correct, or am I misremembering.

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    2. America did and does allow editing. Commonweal never did. I had a hiccup or two when posting here. I'm thinking I accidentally hit the "publish" button twice. "Publish" sounds a bit highfalutin for the stuff I submit. A button that says "zoink" might be more appropriate.

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  7. unagidon here.

    I hope you all like the article. I'll watch here if you have any questions about it.

    I have submitted another article (actually, they have an accumulation of my submissions at this point), which addresses the issue of Medicare For All as a solution for our current problem. I argue that is isn't a solution, much as I would like it to be. The reason is the complicated way that the dollars are locked up in the current system and they way that providers are currently paid. Just establishing Medicare of everyone would not in itself unwind all of this stuff. Medicare for all would make a good model for what the system would need to look like. But the unwinding process of converting all of the money from a private to a public system would need to be done in steps. I didn't outline these in what I submitted to Commonweal. But I do point out that Medicare and Medicaid were constructed for the US private market. The US private market has in turn built itself around the public programs. Neither can stand alone anymore.

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  8. That's interesting. Is it correct that Medicare is not allowed to dicker over pricing with providers as private insurance companies do? If not, does that explain why Medicare alone pays for 80 percent of costs (and could pay a lower percent I'm the future as costs go up)? Does Medicare have an ultimately good or bad effect on the pricing of health care for everyone?

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    1. It's Medicaid that averages about 80 percent. Medicare is between 93 and 98 percent

      But Medicare doesn't deal with prices at all. They calculate a national average and weight it in different ways and then just pays that. The Right doesn't consider this to be a "free market". It is in the sense that there is a limited number of dollars in the reimbursement and providers can get a higher profit if they become more efficient. (The conservatives that participated in the creation of Medicare knew this. I think they used to be higher functioning than they are now). The good affect on health care pricing is that it does create this incentive to hold down costs. The bad affect is that the base reimbursement is still based on averages and not on any negotiation pressures on individual providers. Being based on averages means that the inefficient providers are lumped in with efficient ones in setting reimbursements. This leads the system to pay on its overall mediocrity and it probably pays too much. Now mix into this the growing monopolization that's occurring and the fact that providers are subsidizing themselves with commercial insurance in the manner I outlined in my article and you may see that there is nothing capping costs in an effective way.

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    2. "Efficient" is a loaded word, no? What is "efficient" patient care? Cheapest? Uses least number of interventions? Quickest in and out of the office time? Longevity?

      I think it's hard for consumers to figure out the quality of care. I am thinking of ditching my current oncologist and going to one I saw during a consult whom I liked better. But just because he was more encouraging and personable doesn't mean I'll get better care, does it? You're more informed going in and buying a car than you are picking out a doctor or clinic ...

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  9. I know two nurses, and they seem to work very, very hard at a very difficult and stressful job (dealing with people, yeesh). I don't know how one can squeeze more "efficiency" out of them without ruining THEIR health. The one nurse who's a guy says people think the person who wipes THEIR ass should get $3/hr but they wouldn't wipe someone elses ass for less than $50/hr. The man has a point.

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    1. Good point, Stanley. I think the healthcare industry is very good at squeezing maximum efficiency out of the people actually doing the care, maybe to the point of burning them out. But it is less good at squeezing efficiency out of corporations and institutions.

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    2. I agree. Working for a provider is just like working for anyone else in the sense that they push their workers as hard as they can. When I said "efficiency" I didn't want to suggest that this would be found by squeezing the line staff.

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  10. Katherine, since my primary care joined a healthcare group, paperwork staff dropped from four to two, so I guess there's other ways to cut costs. But I know the most hard working are getting squeezed, too. Sometimes it means having a cardio team on call instead of having them in the building. Could mean the difference between life and death.

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    1. Paperwork staff are being reduced in my clinics b/c doctors have laptops and have to keep records themselves. My primary and cardio like it fine. In fact, they use their laptops as a teaching tool (and to show me pictures of pets). My oncologist hates her laptop. Connection seems to be slow, and she isn't computer savvy. She always jokes that she needs a "scribe." It means she looks at her computer a lot more than at me.

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