RIP the Earth

The Earth will be fine

We might not be ;)

Primate @ 28/3/2017 10:05

Pure single payer loses much of the innovation that our broken down system has been so good at fostering. (Nobels don't lie) Choices and the private sector still need to be involved or I could see the US falling back to the pack.

Actually, single payer does drive some innovation; the problem with health care (and our economic system in general) is that folks tend to say capitalism drives innovation when that is not necessarily true. It drives *profitable* or potentially profitable innovation, but that is it. And health care innovation is not necessarily in areas that drive up outcomes, only costs. For example, MRIs are used for all sorts of things that they provide very little value to, mainly because you can bill out the use of the equipment and get paid for it, whether it increases the value of the outcome for the patient or not. I'm not saying all the MRI use doesn't add value in certain instances, but it is way overused in cases where the value is very little.

The Nobel winners also tend to innovate on items that aren't necessarily profitable, and it's always worth pointing out that Salk specifically didn't pursue a patent for the polio vaccine.* And few kids who want to grow up and be doctors because they want to "cure cancer" say "because then I can make an assload on cancer cures." While there are a number of doctors who are purely profit minded, there are still a significant more who do it for more than just the $$$.




*- Some biotech people argue that Salk could not have gotten one due to "prior art" on the vaccine, but the fact it is biotech people arguing this should have you take it with a grain of salt. It should be noted that Sabin didn't patent his polio vaccine either and that both noted they "donated them to society". But the estimated $ benefit Salk and his estate could have received is estimated at $7 billion, though this number drops to $2-2.5 billion if you factor in a patent expiration date of 20 years.

Primate @ 28/3/2017 9:15

https://www.forbes.com/sites/carolynmcclanahan/2017/03/27/rising-from-the-ashes-a-novel-bipartisan-approach-to-health-care-reform/#766960ee2ab4 Some of the ideas in this plan are really nice. The numbers tell the story, though.

They actually seem to have the reverse issue of mine- catastrophic care goes into the private system. That's a bad idea- adverse selection collapses the pool almost immediately in that case. You can't get premiums high enough to cover the costs for folks.

vladykins @ 28/3/2017 11:08

Primate @ 28/3/2017 9:15 https://www.forbes.com/sites/carolynmcclanahan/2017/03/27/rising-from-the-ashes-a-novel-bipartisan-approach-to-health-care-reform/#766960ee2ab4 Some of the ideas in this plan are really nice. The numbers tell the story, though. They actually seem to have the reverse issue of mine- catastrophic care goes into the private system. That's a bad idea- adverse selection collapses the pool almost immediately in that case. You can't get premiums high enough to cover the costs for folks.

I see your point.
They do later mention specialists acting as consultants and ongoing treatments, etc being done in the CHC setting, with the primary doc and chc serving as more of a case mgr. and point of care duo. If that were the case, I would assume things like chemo, dialysis, radiation, etc would become cheaper with a single payer. That would leave hospital stays, surgeries, extreme emergent care, long term care, and the more complicated diagnostics to the private payers.

I'm not sure if you would have the same issues or not. I imagine it would be up to how many people bought in. I could still see it being an issue since most folks would tend to roll the dice and hope not to catch anything catastrophic.

Primate @ 28/3/2017 14:10

vladykins @ 28/3/2017 11:08 Primate @ 28/3/2017 9:15 https://www.forbes.com/sites/carolynmcclanahan/2017/03/27/rising-from-the-ashes-a-novel-bipartisan-approach-to-health-care-reform/#766960ee2ab4 Some of the ideas in this plan are really nice. The numbers tell the story, though. They actually seem to have the reverse issue of mine- catastrophic care goes into the private system. That's a bad idea- adverse selection collapses the pool almost immediately in that case. You can't get premiums high enough to cover the costs for folks. I see your point. They do later mention specialists acting as consultants and ongoing treatments, etc being done in the CHC setting, with the primary doc and chc serving as more of a case mgr. and point of care duo. If that were the case, I would assume things like chemo, dialysis, radiation, etc would become cheaper with a single payer. That would leave hospital stays, surgeries, extreme emergent care, long term care, and the more complicated diagnostics to the private payers. I'm not sure if you would have the same issues or not. I imagine it would be up to how many people bought in. I could still see it being an issue since most folks would tend to roll the dice and hope not to catch anything catastrophic.

That's the problem. Catastrophic care is what needs covered more than anything; it's the most expensive, it's the least likely to predict (and thus people are more likely to be risky and not go the insurance route) and the others who do want to buy in often have pre-existing conditions. For example, i have a friend who has congenital problems that have recently been discovered (she's about to turn 43). She's always had epilepsy and balance issues and the like, but recently from being hospitalized learned she actually has holes in her spine that if jarred wrong will kill her instantly. She has had trouble getting insurance before and ACA at least helped with that, but if she doesn't get certain meds and has a seizure and fall now, she can die just like that. She is having trouble affording premiums now with people who are required to all be in the insurance pool, but if all the risk takers pull out of the pool, her premiums would skyrocket. She'd have a seizure and be dead. Boom. End of story. There are a ton of people like that out there and adverse selection in insurance requires that people who will never need insurance be in the pool to pay for those who do need it for sure.

Alternative situation: Someone doesn't get catastrophic coverage to roll the dice. Car accident that leaves them with $500k in bills. Since they don't have coverage or a means to pay, do we just not take care of them and leave them in a bloody pulp? Take care of them but basically they owe all their future work earnings to someone else, making them little more than a slave? Do we blame them because they decided to save a little cash?

These two reasons is why i make catastrophic care the key thing that is covered 100%. Adverse selection and people deciding to roll the dice are not sounds economic strategies.

vladykins @ 28/3/2017 13:25

Primate @ 28/3/2017 14:10 vladykins @ 28/3/2017 11:08 Primate @ 28/3/2017 9:15 https://www.forbes.com/sites/carolynmcclanahan/2017/03/27/rising-from-the-ashes-a-novel-bipartisan-approach-to-health-care-reform/#766960ee2ab4 Some of the ideas in this plan are really nice. The numbers tell the story, though. They actually seem to have the reverse issue of mine- catastrophic care goes into the private system. That's a bad idea- adverse selection collapses the pool almost immediately in that case. You can't get premiums high enough to cover the costs for folks. I see your point. They do later mention specialists acting as consultants and ongoing treatments, etc being done in the CHC setting, with the primary doc and chc serving as more of a case mgr. and point of care duo. If that were the case, I would assume things like chemo, dialysis, radiation, etc would become cheaper with a single payer. That would leave hospital stays, surgeries, extreme emergent care, long term care, and the more complicated diagnostics to the private payers. I'm not sure if you would have the same issues or not. I imagine it would be up to how many people bought in. I could still see it being an issue since most folks would tend to roll the dice and hope not to catch anything catastrophic. That's the problem. Catastrophic care is what needs covered more than anything; it's the most expensive, it's the least likely to predict (and thus people are more likely to be risky and not go the insurance route) and the others who do want to buy in often have pre-existing conditions. For example, i have a friend who has congenital problems that have recently been discovered (she's about to turn 43). She's always had epilepsy and balance issues and the like, but recently from being hospitalized learned she actually has holes in her spine that if jarred wrong will kill her instantly. She has had trouble getting insurance before and ACA at least helped with that, but if she doesn't get certain meds and has a seizure and fall now, she can die just like that. She is having trouble affording premiums now with people who are required to all be in the insurance pool, but if all the risk takers pull out of the pool, her premiums would skyrocket. She'd have a seizure and be dead. Boom. End of story. There are a ton of people like that out there and adverse selection in insurance requires that people who will never need insurance be in the pool to pay for those who do need it for sure. Alternative situation: Someone doesn't get catastrophic coverage to roll the dice. Car accident that leaves them with $500k in bills. Since they don't have coverage or a means to pay, do we just not take care of them and leave them in a bloody pulp? Take care of them but basically they owe all their future work earnings to someone else, making them little more than a slave? Do we blame them because they decided to save a little cash? These two reasons is why i make catastrophic care the key thing that is covered 100%. Adverse selection and people deciding to roll the dice are not sounds economic strategies.

That makes sense. Thinking of it that way makes full blown single payer the only real option.

Yep- that's why I go Catastrophic Care 100% and then have all other care "rationed" based on actuarial tables. Demanding more care than is normal in a non-catastrophic sense? You pay 100%. Helps weed out over demand and people who go to the doctor for super minor issues.

LOL

I best become a historian then, since they apparently will survive

vladykins @ 28/3/2017 14:59

Yep- that's why I go Catastrophic Care 100% and then have all other care "rationed" based on actuarial tables. Demanding more care than is normal in a non-catastrophic sense? You pay 100%. Helps weed out over demand and people who go to the doctor for super minor issues.

I'm not crazy about the rationing. I worry that would create gov't hoops to jump through and people who needed care wouldn't get it or you would have to pay for it and fight for reimbursement.

Primate @ 29/3/2017 8:34

vladykins @ 28/3/2017 14:59 Yep- that's why I go Catastrophic Care 100% and then have all other care "rationed" based on actuarial tables. Demanding more care than is normal in a non-catastrophic sense? You pay 100%. Helps weed out over demand and people who go to the doctor for super minor issues. I'm not crazy about the rationing. I worry that would create gov't hoops to jump through and people who needed care wouldn't get it or you would have to pay for it and fight for reimbursement.

The rationing could be done based on actuarial tables- we have huge amounts of data on this already, so it can be tailored to meet individual needs (as I noted previously, pregnant women need more doctor visits than a 20 year old male, so they would be allocated more). remember, we're not talking catastrophic care (cancer, broken limbs, heart issues, etc.). We're talking wellness visits, checkups, and minor issues. The rationing is there intentionally because we as a nation demand way more medical care than is efficient, leading to higher costs, longer wait times to get a doctor, etc. If you know you have two visits left in the year and you get the sniffles, do you go to the doctor or tough it out? If you feel it is worth using up one of those last two visits, then you go for it. And if you use all your visits, then it becomes out of pocket (which means then a secondary market for insurance could kick in). There would also be a secondary market for elective procedures. Rationing also keeps the hypochondriac from going all the time sucking up the doctor's time and everyone's tax dollars on useless bullshit- they use too much and it starts coming out of their pocket.

So, the "needed care" isn't an issue because most necessary care would be covered under rations or catastrophic care.

vladykins @ 29/3/2017 12:17

Primate @ 29/3/2017 8:34 vladykins @ 28/3/2017 14:59 Yep- that's why I go Catastrophic Care 100% and then have all other care "rationed" based on actuarial tables. Demanding more care than is normal in a non-catastrophic sense? You pay 100%. Helps weed out over demand and people who go to the doctor for super minor issues. I'm not crazy about the rationing. I worry that would create gov't hoops to jump through and people who needed care wouldn't get it or you would have to pay for it and fight for reimbursement. The rationing could be done based on actuarial tables- we have huge amounts of data on this already, so it can be tailored to meet individual needs (as I noted previously, pregnant women need more doctor visits than a 20 year old male, so they would be allocated more). remember, we're not talking catastrophic care (cancer, broken limbs, heart issues, etc.). We're talking wellness visits, checkups, and minor issues. The rationing is there intentionally because we as a nation demand way more medical care than is efficient, leading to higher costs, longer wait times to get a doctor, etc. If you know you have two visits left in the year and you get the sniffles, do you go to the doctor or tough it out? If you feel it is worth using up one of those last two visits, then you go for it. And if you use all your visits, then it becomes out of pocket (which means then a secondary market for insurance could kick in). There would also be a secondary market for elective procedures. Rationing also keeps the hypochondriac from going all the time sucking up the doctor's time and everyone's tax dollars on useless bullshit- they use too much and it starts coming out of their pocket. So, the "needed care" isn't an issue because most necessary care would be covered under rations or catastrophic care.

I think you may be underestimating the difficulties of navigating current government systems, especially for the elderly, the uneducated, and the underprivileged. (Often the groups who need the care the most) I could definitely see this thing being set up similarly. It would be something to caution for.

How would your system deal with tough to diagnose illnesses, would the recipient be punished for the doctor's inability to figure out an illness? I ask because my daughter developed a digestive issue in middle school that took us several months with a dozen or more visits and about 15 grand worth of tests before anyone figured it out. Would we have been SOL according to actuarial tables? I also had a friend whose daughter was diagnosed with Crohn's disease as a HS Junior. That took over a year to be properly diagnosed.

Not trying to shoot holes in your system or anything. Just mentioning some of the things that have always worried me about single payer systems.

I guess I include chronic issues under my "catastrophic" category (which is why i made sure cancer went in there). If there is an issue and they can't identify it, then they haven't "completed" a visit in essence. ;)

vladykins @ 28/3/2017 10:54

Primate @ 28/3/2017 10:05 Pure single payer loses much of the innovation that our broken down system has been so good at fostering. (Nobels don't lie) Choices and the private sector still need to be involved or I could see the US falling back to the pack. Actually, single payer does drive some innovation; the problem with health care (and our economic system in general) is that folks tend to say capitalism drives innovation when that is not necessarily true. It drives *profitable* or potentially profitable innovation, but that is it. And health care innovation is not necessarily in areas that drive up outcomes, only costs. For example, MRIs are used for all sorts of things that they provide very little value to, mainly because you can bill out the use of the equipment and get paid for it, whether it increases the value of the outcome for the patient or not. I'm not saying all the MRI use doesn't add value in certain instances, but it is way overused in cases where the value is very little. The Nobel winners also tend to innovate on items that aren't necessarily profitable, and it's always worth pointing out that Salk specifically didn't pursue a patent for the polio vaccine.* And few kids who want to grow up and be doctors because they want to "cure cancer" say "because then I can make an assload on cancer cures." While there are a number of doctors who are purely profit minded, there are still a significant more who do it for more than just the $$$. *- Some biotech people argue that Salk could not have gotten one due to "prior art" on the vaccine, but the fact it is biotech people arguing this should have you take it with a grain of salt. It should be noted that Sabin didn't patent his polio vaccine either and that both noted they "donated them to society". But the estimated $ benefit Salk and his estate could have received is estimated at $7 billion, though this number drops to $2-2.5 billion if you factor in a patent expiration date of 20 years.

There is definitely some innovation, but innovation takes money, and altruism is rare. Single payer puts funding for innovation in the hands of the gov't and a handful of NPO's. The open market still has that funding as well as profit driven funding. The more people backing experiments, the less risk of "inbreeding" and the greater the chance of innovation. Also innovations are never created to make money. It's always done to solve a problem. Privately funded innovations usually have a goal of solving a problem that will also generate profit..