Our Next President?

[geodrome]

Re: Our Next President?

So far Warren is running on:

— Universal day care
— Universal health care
— Universal income (in Green New Deal)
— Universal jobs program (in Green New Deal)
— Write off student loan debt
— Civilian Disarmament aka Gun Control
— Reparation for slavery

[Thailandnotes]

Re: Our Next President?

My understanding is the very best pace to go, high quality for moderate costs for surgical work is Thailand and for dental, Hungary.

Medical tourism is alive and well and expanding in Thailand. New hospitals are being built with different grade hotels next to them. There is an ongoing debate about how much if any this siphons off from the healthcare of the general public. A colonoscopy is still less than 500 dollars, a filling less than 50, and although big pharma is flexing its muscles, many drugs are still 1/10th the cost in the US. In addition, most drugs do not require a prescription eliminating repeated doctor's visits. Hospitals post prices and compete on basic services like complete physicals, stress tests, mamograms. Pharmacies have sales and prices are often negotiable. Surgery like knee replacements are routinely preformed by doctors trained in the US. A large majority of the younger doctors are female, refreshing in a society dominated by men. There is little pressure on doctors to quickly wrap up patient visits. In most inpatient care, the hospital handles all the paper work with your insurance company.

[Chris Coles]

Re: Our Next President?

During 2001 I sat beside another airline traveler who told me he was concerned that his daughter was not planning to become either a doctor or a banker, but instead was determined to become an archeologist. Now I fully understand why he was so concerned.

[dcarrigg]

Re: Our Next President?

All of this because you can't just admit the obvious fact that the federal government controls Medicare pricing?

Congress has the Comptroller General appoint 17 people to a committee that makes non-binding recommendations and you describe this as the hospitals being able to negotiate rates? You can say it's a semantic quibble, but I disagree.

In another context, you would find this laughable. Imagine a union who "negotiates" by having the CEO of the company appoint a committee, who then advises the Board, who then decides in their sole discretion how much to pay the workers. And the union members can individually accept the terms or quit. But they can't talk to each other about what they will accept or they are guilty of price fixing. And the company controls half of the jobs in that industry locally and nationally. Would you say the workers are negotiating their salary?

It would be more like having the board of directors appoint a committee of union members to draw up the first cut at suggested salary rates, then letting HR take that under advisement, then letting HR survey market pay rates for the job, then having a public comment period about salaries in which workers' concerns were heard, then drawing up draft salary rates, then letting the union board chime in again, then allowing workers to bill and account for their time in a variety of complex ways that let them game their salaries up after they sign the contract.

Maybe that's not a negotiation in the pure sense. But it's way closer to it than a CEO just dictating what a job pays. And I'd bet you dollars to doughnuts that wages would be higher and increase every time you went through this process if you were to attempt it today.

That's all I'm saying. So fine, I'll concede the point. Maybe it's not a negotiation in the strict sense. But neither is it rate setting with the intention on controlling costs. If it were, presumably costs wouldn't go up like they do, and healthcare costs might have otherwise stayed as flat as wages.

[DSpencer]

Re: Our Next President?

I tried to explain the process in broad strokes with my numbered list before. Medpac (The Medicare Payment Advisory Commission) is the legislative independent advisory commission made of private practitioners which recommends rates. CMS staff consults with Medpac staff and takes rates and rate policy under advisement. CMS then takes the NHED account survey data of provider rates paid to private insurers. The rulemaking process takes both these factors and public comment into account. Eventually a proposed rule comes out. Medpac comments again, something like this. They tinker again. Eventually, final rules are published in the fed register and set. Then providers decide whether or not they will accept Medicare, and negotiate all sorts of details, and get to recommend a number of their own adjustments and accounting methodologies, as broadly outlined in the provider reimbursement manual. Eventually a contract is signed. Even after this, providers have some flex to affect rates.

So maybe you take issue with how I used the term 'negotiate.' It's not a free for all where a hospital CEO sits on one side of the table and a CMS bureaucrat sits on the other and they haggle rates. But neither is it an adversarial process in which a commission rules on rates and the government defends ratepayers against providers. The reality is different than either of those. The federal government doesn't just set rates. Industry has a huge role in the process, including the opening salvo out of medpac that sets the baseline for the process which I suppose I'm calling negotiation and you don't feel justifies the term. That's fine. Just a semantic quibble. Two points are that 1) providers don't have to accept Medicare at all, and, 2) there are a lot of ways they can push for and work to get reimbursed at higher rates. Hospitals also negotiate cost rates on the NIH and HHS and research side, sometimes as negotiated indirect cost rates (icrs), other times as lump sums.

It's very convoluted. I can get deeper in the weeds, but I don't think it will be very helpful. The physician fees are separate from the facility fees, equipment fees, pharma fees, etc. But if you want to see an example of the rule governing the process, here it is. If you want to understand the mechanics of pricing better, you can play with the fee scheduler. You'll have to know something about HCPCS codes. Suffice it to say pick a letter followed by 4 numbers. So P3001 is a pap smear, for instance. So there's the base. But notice the mods by locality and MAC (Medicare Administrative Contractors, which are private intermediary entities), RVU (relative value units), various status and payment policy indicators, professional and technical components, etc. So roughly this is a broad sense of one side of the Part A and B payments. Part C payments are effectively de facto tied to percentages of the A & B amounts for various convoluted reasons, but are still independently negotiated between providers and private insurers that offer the plans. Part D we all know can't really negotiate with drug companies.

But the whole mess amounts to one simple take-away: It's not like thinking of the federal government as a monolithic price-setting entity is helpful here. Even if one were to do so, it's not clear that the federal government in that case would be either interested in setting rates itself, nor interested in controlling costs, nor firmly on the side of consumers against providers. If anything, the process is heavily run by outside industry, in terms of the role of outside advisory rate recommendations, and in terms of the process requiring private sector negotiated insurance payment rates as input, and in terms of the relative flexibility providers have in negotiating with CMS for various determinations and adjustments that affect ultimate reimbursement rates via contracts. I realize I'm being vague here. I'm also honestly getting a bit out over my skis, as I've never participated in the process directly myself. Regardless, here's a flowchart of the provider reimbursement process even after rate rules are promulgated and contracts are signed by providers to accept Medicare that shows you the effects of some of the post-contract determinations and adjustments I'm talking about.

All of this because you can't just admit the obvious fact that the federal government controls Medicare pricing?

Congress has the Comptroller General appoint 17 people to a committee that makes non-binding recommendations and you describe this as the hospitals being able to negotiate rates? You can say it's a semantic quibble, but I disagree.

In another context, you would find this laughable. Imagine a union who "negotiates" by having the CEO of the company appoint a committee, who then advises the Board, who then decides in their sole discretion how much to pay the workers. And the union members can individually accept the terms or quit. But they can't talk to each other about what they will accept or they are guilty of price fixing. And the company controls half of the jobs in that industry locally and nationally. Would you say the workers are negotiating their salary?

[dcarrigg]

Re: Our Next President?

the problem with standardization is that most treatments involve an n of 1. some procedures should be pretty standardized, although i suppose one practitioner might be more thorough and diligent than another in performing a pap smear, and one path lab may be of higher quality- hard to judge. medicare went to reimbursement for drg's- diagnostic related groups. didn't matter what you did- you were paid a set amount for treating condition x. of course this incentivizes choosing the most highly compensated diagnosis, not necessarily the most accurate one.

btw, doctors are not allowed to talk to one another about their pricing - it's illegal, a violation of antitrust law. if i talk to a friend about my fees i'm committing a crime, because we might gang up on blue cross or aetna.

Yeah, you're right. This is what I meant before when I said we tried every combination of cost-saving scheme imaginable. It's not just on the patient side. It's also on the doc side. And on the insurance side. None of them ever bring costs down. I mean, we've tried literally everything BUT even more complicated nonsense. There's a whole CMS innovation center now just for trying pilots on weird combinations of incentives. Nothing ever works particularly well. And even if something seems to, the effects wash out after the short term.

Ultimately, I see it all sort of like May's Trilemma to keep it topical and up with the news.

You've got 3 motives. Sometimes they're aligned, sometimes they're conflicting. But they conflict in predictable ways.

1. You've got maximum profit on one hand.
2. You've got maximum health outcomes on the other.
3. And you've got efficient pricing on the third.

No matter how convoluted and complex we make the system, there's no way around the inherent conflict in meeting all three of these goals simultaneously. This is why the American system cannot and does not work at the core. Basically, we've settled for decades on the idea that the above list is in priority order, and we can pretty much just ignore 3, so long as we pay lip service to it. The result is runaway costs, middling health outcomes, but the most valuable healthcare sector in the world by far, both in raw terms and as a percentage of the economy as a whole.

[jk]

Re: Our Next President?

the problem with standardization is that most treatments involve an n of 1. some procedures should be pretty standardized, although i suppose one practitioner might be more thorough and diligent than another in performing a pap smear, and one path lab may be of higher quality- hard to judge. medicare went to reimbursement for drg's- diagnostic related groups. didn't matter what you did- you were paid a set amount for treating condition x. of course this incentivizes choosing the most highly compensated diagnosis, not necessarily the most accurate one.

btw, doctors are not allowed to talk to one another about their pricing - it's illegal, a violation of antitrust law. if i talk to a friend about my fees i'm committing a crime, because we might gang up on blue cross or aetna.

[Chris Coles]

Re: Our Next President?

I tried to explain the process in broad strokes with my numbered list before. Medpac (The Medicare Payment Advisory Commission) is the legislative independent advisory commission made of private practitioners which recommends rates. CMS staff consults with Medpac staff and takes rates and rate policy under advisement. CMS then takes the NHED account survey data of provider rates paid to private insurers. The rulemaking process takes both these factors and public comment into account. Eventually a proposed rule comes out. Medpac comments again, something like this. They tinker again. Eventually, final rules are published in the fed register and set. Then providers decide whether or not they will accept Medicare, and negotiate all sorts of details, and get to recommend a number of their own adjustments and accounting methodologies, as broadly outlined in the provider reimbursement manual. Eventually a contract is signed. Even after this, providers have some flex to affect rates.

So maybe you take issue with how I used the term 'negotiate.' It's not a free for all where a hospital CEO sits on one side of the table and a CMS bureaucrat sits on the other and they haggle rates. But neither is it an adversarial process in which a commission rules on rates and the government defends ratepayers against providers. The reality is different than either of those. The federal government doesn't just set rates. Industry has a huge role in the process, including the opening salvo out of medpac that sets the baseline for the process which I suppose I'm calling negotiation and you don't feel justifies the term. That's fine. Just a semantic quibble. Two points are that 1) providers don't have to accept Medicare at all, and, 2) there are a lot of ways they can push for and work to get reimbursed at higher rates. Hospitals also negotiate cost rates on the NIH and HHS and research side, sometimes as negotiated indirect cost rates (icrs), other times as lump sums.

It's very convoluted. I can get deeper in the weeds, but I don't think it will be very helpful. The physician fees are separate from the facility fees, equipment fees, pharma fees, etc. But if you want to see an example of the rule governing the process, here it is. If you want to understand the mechanics of pricing better, you can play with the fee scheduler. You'll have to know something about HCPCS codes. Suffice it to say pick a letter followed by 4 numbers. So P3001 is a pap smear, for instance. So there's the base. But notice the mods by locality and MAC (Medicare Administrative Contractors, which are private intermediary entities), RVU (relative value units), various status and payment policy indicators, professional and technical components, etc. So roughly this is a broad sense of one side of the Part A and B payments. Part C payments are effectively de facto tied to percentages of the A & B amounts for various convoluted reasons, but are still independently negotiated between providers and private insurers that offer the plans. Part D we all know can't really negotiate with drug companies.

But the whole mess amounts to one simple take-away: It's not like thinking of the federal government as a monolithic price-setting entity is helpful here. Even if one were to do so, it's not clear that the federal government in that case would be either interested in setting rates itself, nor interested in controlling costs, nor firmly on the side of consumers against providers. If anything, the process is heavily run by outside industry, in terms of the role of outside advisory rate recommendations, and in terms of the process requiring private sector negotiated insurance payment rates as input, and in terms of the relative flexibility providers have in negotiating with CMS for various determinations and adjustments that affect ultimate reimbursement rates via contracts. I realize I'm being vague here. I'm also honestly getting a bit out over my skis, as I've never participated in the process directly myself. Regardless, here's a flowchart of the provider reimbursement process even after rate rules are promulgated and contracts are signed by providers to accept Medicare that shows you the effects of some of the post-contract determinations and adjustments I'm talking about.

Thank you! Now relate that very convoluted system to the simple process of a face to face auction; where one bids against the actions of other bidders; or, again, when dealing with a purchase of a product from potential multiple suppliers, where one simply states what one wishes to purchase and gets the equally simple answer of related cost.

As I see it, the entire system above is the responsibility of the point of sale; that such complexity should be invisible behind the determination of the cost of purchase. Pap Smear costs and a single price offered from each provider. Any other way brings in such complexity that the whole idea of a free market is completely lost.

Very thought provoking.

[dcarrigg]

Re: Our Next President?

Who has authority to set the prices Medicare pays, other than the federal government?

Can you provide any links to support the idea that hospitals negotiate prices with Medicare?

I tried to explain the process in broad strokes with my numbered list before. Medpac (The Medicare Payment Advisory Commission) is the legislative independent advisory commission made of private practitioners which recommends rates. CMS staff consults with Medpac staff and takes rates and rate policy under advisement. CMS then takes the NHED account survey data of provider rates paid to private insurers. The rulemaking process takes both these factors and public comment into account. Eventually a proposed rule comes out. Medpac comments again, something like this. They tinker again. Eventually, final rules are published in the fed register and set. Then providers decide whether or not they will accept Medicare, and negotiate all sorts of details, and get to recommend a number of their own adjustments and accounting methodologies, as broadly outlined in the provider reimbursement manual. Eventually a contract is signed. Even after this, providers have some flex to affect rates.

So maybe you take issue with how I used the term 'negotiate.' It's not a free for all where a hospital CEO sits on one side of the table and a CMS bureaucrat sits on the other and they haggle rates. But neither is it an adversarial process in which a commission rules on rates and the government defends ratepayers against providers. The reality is different than either of those. The federal government doesn't just set rates. Industry has a huge role in the process, including the opening salvo out of medpac that sets the baseline for the process which I suppose I'm calling negotiation and you don't feel justifies the term. That's fine. Just a semantic quibble. Two points are that 1) providers don't have to accept Medicare at all, and, 2) there are a lot of ways they can push for and work to get reimbursed at higher rates. Hospitals also negotiate cost rates on the NIH and HHS and research side, sometimes as negotiated indirect cost rates (icrs), other times as lump sums.

It's very convoluted. I can get deeper in the weeds, but I don't think it will be very helpful. The physician fees are separate from the facility fees, equipment fees, pharma fees, etc. But if you want to see an example of the rule governing the process, here it is. If you want to understand the mechanics of pricing better, you can play with the fee scheduler. You'll have to know something about HCPCS codes. Suffice it to say pick a letter followed by 4 numbers. So P3001 is a pap smear, for instance. So there's the base. But notice the mods by locality and MAC (Medicare Administrative Contractors, which are private intermediary entities), RVU (relative value units), various status and payment policy indicators, professional and technical components, etc. So roughly this is a broad sense of one side of the Part A and B payments. Part C payments are effectively de facto tied to percentages of the A & B amounts for various convoluted reasons, but are still independently negotiated between providers and private insurers that offer the plans. Part D we all know can't really negotiate with drug companies.

But the whole mess amounts to one simple take-away: It's not like thinking of the federal government as a monolithic price-setting entity is helpful here. Even if one were to do so, it's not clear that the federal government in that case would be either interested in setting rates itself, nor interested in controlling costs, nor firmly on the side of consumers against providers. If anything, the process is heavily run by outside industry, in terms of the role of outside advisory rate recommendations, and in terms of the process requiring private sector negotiated insurance payment rates as input, and in terms of the relative flexibility providers have in negotiating with CMS for various determinations and adjustments that affect ultimate reimbursement rates via contracts. I realize I'm being vague here. I'm also honestly getting a bit out over my skis, as I've never participated in the process directly myself. Regardless, here's a flowchart of the provider reimbursement process even after rate rules are promulgated and contracts are signed by providers to accept Medicare that shows you the effects of some of the post-contract determinations and adjustments I'm talking about.

[DSpencer]

Re: Our Next President?

I guess I just want to be clear about one thing:

The federal government does not regulate the prices Medicare pays for healthcare services in any way that's recognizably true price regulation. The federal government does negotiate the prices Medicare pays for healthcare services to an extent.

Who has authority to set the prices Medicare pays, other than the federal government?

Can you provide any links to support the idea that hospitals negotiate prices with Medicare?

[dcarrigg]

Re: US College for my Girl? NO F-ing way!

Your law is today under the influence of a national belief that any attorney may create any legal document without any ethical constraints whatever. If "I" write it down and some fool, (who does not fully understand the implications), signs it; that is LAW; simple and incontrovertible.

This is an old idea in the United States. And there are those who still hold that the Lochner Era was a good thing, because they believe in this kind of unethical chicanery is a natural right and they call it Freedom of Contract. Of course, all it really ever amounts to is license for the powerful to abuse the weak. And it always gets traction in tandem with increasing inequality. The two are inexorably linked.

[Chris Coles]

Re: US College for my Girl? NO F-ing way!

Republicans an Democrats have let FIRE get away with mayhem for decades. They've done the same with healthcare.

Both parties are bought and paid for.

Government at all levels is too large and inefficient. Many corporations are too. Too many business categories are anti competitive and exclude
innovation.

The left has caused education to become bloated and biased. It was biased on the right 50 years ago then started shifting toward reasonably moderate. Now it's gone too far left. There is no questioning, no respect for other opinions, no debate and no opening of minds.

This is why both parties must be replaced and the entire system rebooted to serv all Americans.

It has come as a surprise to me, as a UK citizen, the full extent of the underlying difficulties faced by those of you on the other side of the proverbial pond. My journey of understanding of why, really started with reading Gold Warriors, America's Secret Recovery of Yamashita's Gold by Sterling and Peggy Seagrave. How a huge sum of money gave essentially unlimited funding to a very small group with no ethical anchor. With that core leadership, deep within the US establishment, acting without proper oversight; particularly without an ethical foundation based upon true freedom; has produced what I believe to be a new form of feudalism.

Here in Europe, we still live in an essentially feudal environment; very small families holding absolute power over their citizens. As I see it, what was forgotten, or again, misunderstood, is that feudalism can only exist if there is an administration that will support it. I might come into possession of a great fortune, but that does not give me access to the levers of power to control a nation. What gives access is bureaucracy; the faceless bureaucrat, someone behind the scene that acts, supposedly, as merely the means to deliver democratic decisions. But they find, over time, that they have complete control. A VERY good example here in the UK is how, when the integrity of the UK civil service comes up in open conversation; the politician will always state they are the very finest; or again, when the politician is briefed against, they will never comment when briefed against. What you end up with, as we here have today is a new form of mafia; an organisation totally dedicated to their own needs; totally secretive, (I once brought this matter up on The Times newspaper web site and heard that soon after, a leading politician decided to sit in on one of the primary civil service meetings in Downing Street, [we discovered some years ago that they have, far and away the best office for such meetings in Downing Street, which is NOT available to the politicians], the result being that the civil servants involved were most put out by his sitting in on their meeting and claimed that his actions were unconstitutional).

Once a nation has an organisation embedded within that has it's own agenda, with their primary discussions deliberately out of the earshot of the democratically elected politicians, then you end up with, as an excellent example.... https://uk.news.yahoo.com/chancellor...093900625.html The decision taken by the UK Ministry of Defense bureaucracy, (who are very obviously under the complete control of the US CIA), was presented to "a friendly" politician, who did not tell anyone else...... enough to make one laugh if it was not so sad a situation.

But these are the UK's problems. As I see it, the underlying problem; the core reason for the ongoing difficulties faced by the US citizen is a failure to create a non politicised system to deliver the rule of law. Especially law based upon ethics. That once you have embedded within the nation a primary leadership group unable to display ethics; you get mission creep. The word gets out that it is OK to ignore ethics and once that sets into motion the entire legal system; the underlying framework for all decisions made under the rule of law; particularly commercial law; becomes debased. An excellent example being when the likes of Microsoft, or, again, Adobe, deliberately set out to climb through the windows of every one of the previous customers to destroy the software that their customers bought under classic free market terms; paid for and thus owned by the customer; so that the customer is forced to buy a new product; or NEVER again have access to their work previously produced by that once free market software.

Now, imagine that everyone that had historically purchased a fine example of porcelain had to "enjoy" the destruction of their purchase, then NONE would exist today. Go and google images ancient porcelain and accept that all would have been destroyed as a "normal" part of the evolution of the product.

What the lack of ethics has done is very effectively destroy your nation's integrity. Your law is today under the influence of a national belief that any attorney may create any legal document without any ethical constraints whatever. If "I" write it down and some fool, (who does not fully understand the implications), signs it; that is LAW; simple and incontrovertible.

The United States has lost it's ethical foundations and will, as a result; fail.

[vt]

Re: US College for my Girl? NO F-ing way!

Republicans an Democrats have let FIRE get away with mayhem for decades. They've done the same with healthcare.

Both parties are bought and paid for.

Government at all levels is too large and inefficient. Many corporations are too. Too many business categories are anti competitive and exclude
innovation.

The left has caused education to become bloated and biased. It was biased on the right 50 years ago then started shifting toward reasonably moderate. Now it's gone too far left. There is no questioning, no respect for other opinions, no debate and no opening of minds.

This is why both parties must be replaced and the entire system rebooted to serv all Americans.

[vt]

Re: Our Next President?

I've been with Kaiser in the Virginia area for 5 years. It is the most efficient, best service, good doctors I've ever seen.

Wife and I use for Medicare supplemental and cost savings far better than others.

I have my employee covered by Kaiser for about 40% less than other programs.She is not on medicare; only 55. I pay 100% of her
health care.

Kaiser can also cover vision, dental, and hearing for a small amount more.

Kaiser just announced discount meal delivery, medical alert system, and personalized home care.

Kaiser should be the model for health care nationwide.

Doctors are salaried and have full benefits.

[Polish_Silver]

US College for my Girl? NO F-ing way!

Hear, hear! I was talking in an earlier thread about the US potentially becoming a net exporter of students by 2030. And this will be a big part of that.

I will not shell out $200k for my girl to go to US college.
Not worth it.
She'd be better off to put the $200k in dividend stocks and take a two year course in pipe welding.
Come out of it with near 0 debt and excellent career prospects.

What I expect is that she will go to college in Canada or central europe (she is fluent in Polish).


The perspective she will get from 4 years in another country would greatly out weigh any advantage
from going to a "top school" in America.

(And I'm the one who studied at one of these "top schools")

Tuition and Health Care: the public policy & cultural bogies that are ruining this country, even more than FIRE and the Military.
(not that the military cost isn't bad eough)