Surgeon vs. Plumber

Discussion in 'Too Hot for Swamp Gas' started by gatordpm, Sep 10, 2013.

  1. Row6
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    Row6 New Member

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    You mistake a speculative housing and land bubble fueled by mortgage bankers and investors for steadily exploding costs to build. We had the former, not the latter, a few years ago. The latter characteristics are what define the American health care industry.
  2. Row6
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    Row6 New Member

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    OK, that makes sense, and is obvious when you describe it. So specialist status, prestige, and autonomy are based on their market value - of course, and sorry to not get it before. So, how can that be changed without waiting for everyone - or the hospitals - to just do the right thing?
  3. QGator2414
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    QGator2414 VIP Member

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    What is bankrupt and what has been bailed out?

    Medicare is bankrupt unless we redistribute those under 65's earnings and is actually bankrupt if we continue that without increasing the redistribution or cutting benefits.

    The industry that keeps you in business almost brought this country to its knees (some would say it did) with easy money and government guarantees.

    If we let the free market do its thing we will thrive. People were not dying on the streets or in hospitals before government jumped into healthcare at unprecedented levels back in the 60's. So why can't the free market work? It works for you and your industry to provide shelter (except when we guarantee loans and remove risk from the banks and bail them out). It worked before government took over and allowed e fascism we now have.

    But since you feel the free market is incapable of controlling costs why are you not for nationalizing the industry that gives you the ability to charge outrageous prices as a general contractor (yes that is sarcasm as I want you to be able to charge what you think your services are worth to build proper shelters for people but I want you to afford the same to your fellow citizens)? You make people go into debt that could bankrupt them one day yet you are not concerned about that. So again I just want you to afford the same privileges you desire to others.

    I just figured if you are so concerned about costs you would want to make sure general contractors like yourself are not allowed to gouge customers (yes I do not believe this but continue to hope row will get it).
  4. sappanama
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    sappanama VIP Member

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    and you confuse physician salaries with the skyrocketing health care costs.

    and i built a house in 1995 for 115 dollars a foot, 18 years later 12 miles away the same house (wife loved it) with different granite and kohler vs american standard fixtures cost 207/foot. so yeah the latter is in play too
  5. sappanama
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    sappanama VIP Member

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    then your beef is definitely not with the doctor, I know of no doctor who doesn't post charges, or tell you exactly what a visit or procedure costs.

    now hospitals are a different game for a variety of reasons, chief among them accounting tricks, fed gov't subsidies, and creation of confusion in collusion with the insurance and drug companies as well as the government.

    next time you go to your doctor ask him what the cash payment option is and see how much push back you get, it will be utterly absent i promise you.
  6. Row6
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    Row6 New Member

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    I never said physician's salaries were responsible for our out of control health care costs.

    "...We do know one thing from economic research: one-year home price increases, after correcting for inflation, have had almost no statistical relationship to increases 10 years down the road. Thus, the upturn last year is irrelevant to long-run forecasting. Booms are typically followed by busts, usually in far less than 10 years. In a decade, an entire housing boom, if there is one in inflation-corrected terms, is likely to have been reversed and completely washed away....

    Home prices look remarkably stable when corrected for inflation. Over the 100 years ending in 1990 — before the recent housing boom — real home prices rose only 0.2 percent a year, on average. The smallness of that increase seems best explained by rising productivity in construction, which offset increasing costs of land and labor."​

    http://www.nytimes.com/2013/04/14/business/why-home-prices-change-or-dont.html?pagewanted=all&_r=0

    The rate of general inflation since 1995 is about 65%. Maybe the Kohler stuff added the rest, though if you are in Florida, code changes would impact structural issues, AC efficiency minimums, window performance, and oil has more than doubled the cost of buying shingles.... and so on. None of this adds up to what has happened in health care.
  7. Row6
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    Row6 New Member

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    In depth article and series touches on some of the same issues discussed on this thread.

    Harvard Business Review has an on-line series on how to fix our medical system problems and will host a "webinar" this Friday. There is also an on-line forum.

    "Why Health Care Is Stuck — And How to Fix It"

    - Providers are organized and reimbursed around what they do, rather than what patients need.

    Most health care delivery organizations are organized around physicians and specialties. Within a hospital, physicians are members of the departments and divisions and specialize in what they were trained to do. They treat a broad range of conditions relevant to their field—for example, a neurologist will see patients with headaches, provide stroke care, and treat multiple sclerosis and other conditions with a neurological component. Physicians are physically located in their specialty units, and patients are expected to find their way to them. In this structure, physicians generally work hard to help patients during each encounter – and their assumption is that if they do so, they are doing their job. In this context, their efforts to improve care have focused largely on raising the volume of the discrete services they provide, with “efficiency” gauged in terms of “throughput.” ......

    -Free-agent physicians operate independently, rather than as part of an integrated team.

    Not only is care siloed by specialty, but much specialty care in the U.S. is delivered by independent physicians in private practice. A study of Medicare patients, for example, showed that patients saw a median of seven different physicians in four different practices each year, with little or no integration among them....

    - Patient volume is fragmented, making every patient a special case.

    Health care systems in virtually every country, including the U.S., disperse rather than aggregate patients with similar needs. A century ago, hospitals sprang up in almost every small town or city, and served any patient walking in the door. This made sense when there was not much that medicine could do for many patients beyond relieving their symptoms. Because hospitalizations could easily last a month or more, close proximity was essential to allow visits by family members. The result was that most providers treated a relatively small number of most types of cases.

    Today, however, medicine is far more advanced and specialized and lengths of stay are much shorter....

    - Massive cross-subsidies in reimbursement for individual services have distorted care and stalled care integration.

    Under the prevailing fee-for-service payment system, there is a loose relationship at best between the fees paid and the actual costs of performing that service. Flawed reimbursement methodologies have made some services lucrative (for example, radiology and chemotherapy), while others are reimbursed below actual costs (mental health and palliative care, for instance). Organizations use high-margin services to cross-subsidize the money-losing areas, with severe, perverse consequences. Virtually every provider organization is motivated to invest in profitable services like bariatric and vascular surgery in a desperate grab for enough lucrative business to stay alive. The result is excess capacity and overprovision of these services, yet insufficient volume for most providers to deliver excellent or efficient care.

    - No participant in the system has good information about patient outcomes and the cost of care.

    Flying blind is dangerous. When there are no data on how you are doing, and whether new interventions or practices actually improve outcomes or lower costs, initiatives to improve performance can end up doing more harm than good.

    - Information technology has often made care integration and value improvement harder, rather than enabling it.

    Most clinical information systems have been designed around specialties, procedures, or care sites, and focused on scheduling and fee-for-service billing. Few systems were designed to keep track of individual patients over a full care cycle, and provide all the caregivers involved with comprehensive patient information. Few if any clinicians involved in the care of a patient have complete information. Information systems can also make it almost impossible to collect information on outcomes that matter. Highly relevant data (for example, incontinence or falls) are not captured in EMRs at all, and much outcome information is buried in “free text” fields within clinician notes, which makes it hard to extract or act upon....

    http://hbr.org/special-collections/insight/leading-health-care-innovation?query=pfw
  8. Swampmaster
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    Swampmaster New Member

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    doctors should not take any medicare / medicaid patients due to the low reimbursement rates and high costs of paperwork compliance, etc. Just take patients paying cash or with regular insurance policies that pay high reimbursement rates.
  9. ArtDeco
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    ArtDeco Well-Known Member

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    Row,
    I don't know who wrote this article, but surely after reading my posts to you, you can now see this article is VERY biased. This article was written with one goal in mind, to galvanize support for a large behemoth healthcare delivery system that can easily be controlled by government (easier to negotiate with one doctor group than 50) and easier for the hospitals to get your business.This report makes MSNBC look objective!
    I will now take time out of my busy day to educate you once again, as you seem receptive towards finding answers, not stirring up talking points. In keeping with that spirit, please refrain from posting articles or talking points from liberals or cons or groups with political agendas. Every time I see you respond to some noodnik post with a liberal comeback, I honestly question whether you truly appreciate this or not.
    Here goes, if you are interested:

    "Why Health Care Is Stuck — And How to Fix It"

    - Providers are organized and reimbursed around what they do, rather than what patients need.
    This is the single most dangerous idea floating out there today. It's called pay for performance, but really, it should be called "I want a lot of visits for the cost of one". My accountant doesn't charge me per tax return, they charge by the complexity. My computer repair person charges by the hour. My electrician charges not for the job, but how long it takes out of his day.
    Believe it or not, we already have a version of this in Medicare. If a person comes in for a wart removal one day, and then comes in 3 days later with strep throat, Medicare will not cover both visits. Even though the 2 are unrelated, they occurred too close together. If you expand this idea to all of healthcare, guess what will happen: (1) doctors will cherry pick patients who never bother them, the "healthier patients", and leave the truly sick to fend for themselves, and(2) hospitals will be less reluctant to readmit patients who were just there. So if you get pneumonia after a recent bypass, good luck trying to get the hospital to essentially readmit you for free. If somehow there are people dying in the streets now as liberals claim, baby, they haven't seen nothing yet.



    -Free-agent physicians operate independently, rather than as part of an integrated team.
    See, here's the article's obvious bias. The writer obviously wants you to visit his multispecialty clinic. Free thinkers are EXACTLY what you want as a patient. When you're wondering whether to trust your doctor when he's proposing a risky procedure, would it make you feel better to know he has no vested interest in what you're discussing, or would you be worried to know he's paid company dividends for the procedure he's recommended, b/c he referred you to his "partner" in the group right down the hallway?
    Again, use my example. I'm a solo doc. I owe nothing to anyone. If I recommend you go somewhere, it's b/c it's best for your condition, not because I get some kind of payback. I may send one guy this direction b/c they need the best urologist, I may send you to the other hospital b/c they have the best oncologist. You WANT choice, should demand choice, and you should want a physician who's financially independent of the options you're given.
    There's a big "Medical Center Clinic" by us, full of every specialty you can name. I never use them. Why? If you send a patient there for an ingrown toenail, the podiatrist will send them to their partner the infectious disease guy, who will want their neighbor the rheumatologist to look at the toe, who will need the opinion of their office's orthopedist, who will recommend their own cardiologist listen to you. That's why in an earlier post, I referred to what you experienced as the "mill" or the "merry-go-round". It's unethical, unscrupulous, but it happens often with these big groups. And the writer wants you to think this is a good thing. $30,000 later, your toenail's fixed.




    - Patient volume is fragmented, making every patient a special case.

    Again, a liberal argument. If you live in Florida, they want you to go to Atlanta for dialysis, along with all other dialysis patients in the SE.
    Being a "special case" to your doctor is a bad thing?


    - Massive cross-subsidies in reimbursement for individual services have distorted care and stalled care integration.

    Under the prevailing fee-for-service payment system, there is a loose relationship at best between the fees paid and the actual costs of performing that service. Flawed reimbursement methodologies have made some services lucrative (for example, radiology and chemotherapy), while others are reimbursed below actual costs (mental health and palliative care, for instance).
    This is again another way to chop down the fee for service argument. You've gotta give the writer credit, he's trying to do his best hack job, even if what he says doesn't make any sense. Again, he's looking at it from the hospital point of view. Chemo is NOT lucrative for the oncologists, I know that for a fact. My oncologist mentor tried to talk me out of practicing in Florida b/c of the low reimbursements. He showed me his payment from Tricare, it was cents on the dollar.
    Anyway, my point is, read the heading, and tell me what "massive cross-subsidies" really means. sounds good, doesn't it? But it's German. Or ebonics. Meaningless.


    - No participant in the system has good information about patient outcomes and the cost of care.
    - Information technology has often made care integration and value improvement harder, rather than enabling it.
    And lastly, I grouped these two together b/c this is the biggest scam perpetrated on doctors and patients ever. The all-knowing, omnipresent complete chart of everything you've ever done, from stubbing your toe to contracting Gonorrhea. "Integration" and "outcomes" and "electronic data records" is all about control. It's not about improving outcomes. Think about it. If I've got a patient with a surgical abdomen, what helps him faster, calling the surgeon I know, or culling through tens of thousands of pages of meaningless records? The records I receive today from most specialists are useless. Every note looks and reads the same. Basically, every note is built to a template to ensure maximal reimbursement from insurance, so in effect, I've got to wade through three pages about their dog and cat and their marriage status to get to the part about their distended abdomen. I've even had reports from cardiologists where I've sent the patient for atrial fibrillation, there's a big four page note about all they've discussed and all they offered for treatment, and the actual exam still says "regular rate and rhythm"!! Electronic records are not BETTER information, it's more volume of meaningless, and often erroneous information.

    If you don't believe me, go request a copy of your chart from your doctor. See how much of it is drivel, and how much actually dealt with your problem. Prior to 2010, I bet your notes will be short, concise, and to the point of your visit. After about 2010, watch all your notes lengthen to 3-4 pages, and by the time you're done, you won't even know what the purpose of the visit was.
  10. Row6
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    Row6 New Member

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    I'll read your long post later - I have work to do - but, besides for thinking an article published jointly in the prestigious The New England Journal of Medicine and the Harvard Business Review is a "liberal opinion piece", you are contradicting that which you said only a few days ago. To wit, the first two items are exactly what we discussed and I thought we agreed on, i.e., the reign of specialists and lack of an organized approach to a patient's needs. You also criticized procedure based reimbursements, as does this article. Beyond that, while we have managed some agreement - I thought, perhaps mistakenly - you and I may ultimately have different goals. As I said from the beginning, I favor universal and affordable health care - for individuals and the nation - which may or may not inconvenience docs. I hope it doesn't , but that isn't my top priority.​
  11. ArtDeco
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    ArtDeco Well-Known Member

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    So when I explain to you what happened in your personal interaction with the system, I'm a respected expert and you appreciate the sentiment, but when I disagree with some stupid article with an obvious agenda, I'm a liar?

    nm- cooled off

    Maybe you should read my points first, before you dig your ideological heels in the ground.
  12. ArtDeco
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    ArtDeco Well-Known Member

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    Read my post again, shelve all that political BS that these other posters here stir up, and then I'll accept your apology when you cool off. Forget the liberal tag if that's what ticked you off. You made it sound like you had just gone through the ringer in the hospital with multiple specialists and no clear plan. This article says that a guy like me should be on the hospital payroll directing the merry go round. Look, the problem is you didn't have a private doc like me to tell you what to do. I have no desire to work for the hospital- oh, I'm sorry, "work in an integrated system", as the article suggests- and be one of the guys looting your pockets.

    Maybe one of the problems is, since you're not in medicine, you can't read between the lines of the article, whereas I can see exactly what they are saying in code words.
  13. ArtDeco
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    ArtDeco Well-Known Member

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    This has already started happening. Most doctors nowadays do not accept either. Except hospital-employed doctors, b/c their hospital CEO overlords think it's worth it to get the Medicare admissions, even if the doctor's practice itself posts a loss.

    I went into private practice in 2004, and all my colleagues encouraged me to take cash only. I quit taking Medicaid in 2005 (tired of getting $2- literally,$2- for complicated patients that could turn around and sue me for millions), and last year, I quit taking Medicare Advantage plans. Not because of pay, they actually pay well, but because of these tremendous amounts of paperwork these plans require every year (they basically want a copy of all our records each year, every single thing we've done or ordered, in case the government audits them).
    What some posters here don't understand is the tremendous amount of red tape generated by the guvment, and I didn't spend 11 years of my life in training to be a secretary. In 2013, when I write for a wheelchair for a patient, that script creates a 5 page document for me to fill out completely with the threat of jailtime if I mislead Medicare in any way.
  14. QGator2414
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    QGator2414 VIP Member

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    Art you sound like my doctor and I rave about him when people ask about a doctor...

    I did not listen to him one time as a NP (nothing bad to say about the NP) in town had a son who went to preK with my daughter and worked for a cardiologist. So trying to be nice I went to that practice instead of the referal practice by my doctor. We joke to this day about that mistake...
  15. AndyGator
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    AndyGator Well-Known Member

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    My daughter just had knee surgery. 45 minutes. Even with insurance my part of the bill is way more than a mere $800.

    But I do most of my plumbing myself. But not my surgery. Personally I appreciate PDMs education. I'll let you anti-education folks use the non-college doctors. I'll pay for the educated guy :wink:
  16. Gatorrick22
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    Gatorrick22 Well-Known Member

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    Lol... :whistle:
  17. Row6
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    Row6 New Member

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    UH, just when I was beginning to like you you're oozing the doc arrogance that some in your profession are well know for. You won't be getting an apology from me - did I insult your dog? - and I am also busy, but more than willing to give you the benefit of my experience as a patient and and patient wing man. I don't expect a "thank you" but I'm not handing them out either.

    Sorry, but you totally missed the point on at least the 1st two bullet point items in the article, which refer specifically to the "nobody at the wheel" problem in hospitals which we previously discussed. I kind of lost steam on seriously considering your response to the others though I did read them, partly because I wondered if you seriously considered them given the nature of your response to the first two, and partly because you seem to advocate a system without hospitals run by guys in white hats like you. I'm sure you probably do wear one in real practice and care about your patients above making an extra buck, but short of a spiritual reawakening in America, I think we have to rely on rules to curb the excesses of a medical system run amok. It will unfortunately include a bunch of hospitals run by somebody. If you docs can take it over and straighten it out and make even more money - do it! But I don't see a proposal from you for this other than "trust guys like me but f..k those hospital administrators". Where's the beef?

    I don't endorse every proposal in the article because I don't fully understand them all, but your knee jerk reaction and assumption of a motivating plot is not conducive to a rational discussion. Suffice it to say that the article is part of an online forum open to participants and perhaps you should join in it, where your comments would probably be more meaningful and with more impact on influential people in the medical community than one aimed at gator fans with too much time on their hands. If you do, please let us know and I'll follow along.
  18. ArtDeco
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    ArtDeco Well-Known Member

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    LOL~!~!!!!!
    I'm beginning to think you deserve all the epithets the other guys on here throw at you. I was in the middle of an enlightening discussion, and in one day, you revert to some Obama know-it-all who thinks by pinning an article to a post, you now truly know what's wrong with the US system.
    While you're throwing around terms like arrogant, would you not agree it's arrogant for a builder to tell a doctor how to run medicine? I know what I understand, but I also know the limits of my understanding. I will never post on here how to frame a house, or how to replace a carburetor, or how to construct a bridge. You would be well served to learn the limits of your understanding as well and learn from those that are willing to teach you. I see now I have wasted a week of my life trying to get you to understand the system.
  19. ArtDeco
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    ArtDeco Well-Known Member

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    Here's the topics in question:
    - Providers are organized and reimbursed around what they do, rather than what patients need.

    -Free-agent physicians operate independently, rather than as part of an integrated team.

    The first has absolutely nothing to do with "who's at the wheel".

    I already explained to you what the second means: Translation- go to a multispecialty clinic where are the doctors are employed by a corporate entity and where their salaries are determined by how much revenue they bring into the group. What you needed was someone independent, not part of the "integrated system", advising you. Surely you had an admitting doctor, right? That's your main doctor, but I promise you he was probably paid by the hospital, and he keeps you there until the specialists are done with you. He is the perfect example of an "integrated system", and that's what the article says you need. So in other words, you got the care you are demanding by your support of that silly article.
    I don't need an "integrated system" where I make my living based on what a corporation wants to pay me, all I need to be "integrated" is to have a couple good surgeons, ENTs, and orthopedists to pick up a phone and call me. Thankfully, I have all that where I live. No, we don't all operate under the marvelous "Mayo" banner, no we don't have flashy websites or TV ads, no we don't all work in the same group with the same electronic records, but we do our job and we do it better than anyone else.
  20. ArtDeco
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    ArtDeco Well-Known Member

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    Thank you, Q.
    Be glad your profession doesn't have to deal with all this. I had someone call today (maybe it was our favorite poster?) to complain about a bill. They started off by insulting my biller, saying how dare we charge $177 for my service, etc. Then we my biller got down to the facts of the matter, we charged their insurance $100+, got paid about 70% of that, and the patient owes us $2. So basically, someone called up and insulted me personally and professionally over $2.

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