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Politics : View from the Center and Left -- Ignore unavailable to you. Want to Upgrade?

To: Lane3 who wrote (76179)	7/24/2008 7:52:44 AM
From: Lane3	Read Replies (1) \| Respond to of 543213

I'm posting this piece from the NYT to illustrate the "damned if you do, damned if you don't" nature of cookie cutter community medical payment systems. One approach produces waste with their added costs. The "solution" proposed likely would produce underservice and potentially higher costs long term. If you try to avoid the problem pair by throwing in an auditor, you add cost that might exceed the cost of either problem. No good solution to how to handle the commons regarding health care. You could remove it from the commons, that is privatize/individualize it, but then you have other problems, not costly problems, but still problems. Paying Doctors to Ignore Patients By PETER B. BACH Published: July 24, 2008 THE longstanding push-pull between Medicare and Congress has erupted again. Last week, Congress, overriding a presidential veto, canceled Medicare’s scheduled 10.6 percent cut in payment rates for doctors, and instead raised the rates 1.1 percent. But this action fails to address the problem with the Medicare payment system, which is not the amounts doctors are paid but the way their payments are calculated. Medicare pays doctors for specific services. If a patient has a checkup that includes an X-ray, a urine analysis and a physical, Medicare pays the doctor three separate fees. Each fee is meant to reimburse the doctor for the time and skill he or she devotes to the patient. But it is also supposed to pay for overhead, and this is where the problem begins. To Medicare, a doctor’s overhead (or “practice expense”) includes such items as rent, staff salaries and the cost of high-tech medical equipment. When the agency pays a fee to a doctor who has performed a CT scan, it is meant to cover some of the cost of buying or leasing the scanner itself. Services using more expensive equipment generate higher fees. Any first-year business school student can see the profit opportunity here. The cost of a CT scanner is fixed, but a doctor earns fees each time it is used. This means that a scanner becomes highly profitable as soon as it’s paid for. In contrast, the doctor-patient visit, which involves no expensive equipment, offers no significant profit opportunity. So the best way for a doctor to make money in his practice is not to spend time with patients but to use equipment as much as possible. That means moving the maximum number of patients through the practice, and spending the minimum amount of time with each one. From 2000 to 2005, the number of Medicare patients seen by doctors increased by 8.5 percent, while the number of services each one received was up 14 percent, according to the Government Accountability Office. It’s not only Medicare that pays doctors on a fee-for-service basis; most private insurers do also. This is part of the reason that spending on physician services nationwide has risen every year since 2000 by about $25 billion. This year the tab will exceed $500 billion. Doctors who do their own CT scanning and other imaging order roughly two to eight times as many imaging tests as those who do not have their own equipment, a 2002 study by researchers at the University of North Carolina found. Altogether, doctors are ordering roughly $40 billion worth of unnecessary imaging each year — which adds up to nearly 2 percent of the total Americans pay for health care. No wonder the Government Accountability Office last month urged Medicare to find a way to constrain doctors’ use of imaging tests. Over the years, Congress and Medicare have made various attempts to stamp out some of the most egregious excesses in Medicare payments. Sometimes they have succeeded. In 2004 and 2005, when Congress lowered the fees associated with anti-testosterone drugs used to treat prostate cancer, urologists and other doctors prescribed them less. Around the same time, though, urologists started buying multimillion-dollar radiation therapy machines for treating prostate cancer. Reimbursement for radiation treatment remains very generous. Clearly, scattershot strategies aimed at individual fees are unlikely to reduce health care costs. More fundamental changes are needed in the way doctors are paid. For their time, doctors should be given a stipend for each of their patients. It should be larger for patients with complicated medical conditions and smaller for those who are healthy, and it should not be influenced by the number of services or tests a doctor orders. For overhead, doctors should be paid an amount that covers the typical cost of tests and treatments needed to address a patient’s condition. This strategy — known as “case rate” or “prospective” payment — is standard in American hospitals. The hospital receives a payment for dealing with a patient’s underlying condition rather than individual payments for each test and treatment. This approach offers no incentive to run unneeded tests, and it has been credited with substantially slowing the growth in Medicare payments to hospitals. Without changes to the way Medicare pays doctors, the fights in Congress over raising or lowering payment rates will continue. And doctors will still have no financial incentive to do what is most important: spend more time with their patients. Peter B. Bach, a doctor at Memorial Sloan-Kettering Cancer Center, was a senior adviser to the administrator of the Centers for Medicare and Medicaid Services from 2005 to 2006.

To: Lane3 who wrote (76179)	7/24/2008 10:12:48 AM
From: epicure	Respond to of 543213

fascinating

To: Lane3 who wrote (76179)	7/24/2008 2:11:53 PM
From: TimF	Read Replies (1) \| Respond to of 543213

while others suggested the voters were not so much fools as, uh, "cognitive misers." The term I've seen used is "rationally ignorant". Because learning a lot in order to rationally cast your vote, from the details and facts, to achieving an informed understanding of what they mean, takes time and effort, and because fully understanding the publicly stated positions and policy ideas of politicians also takes time and effort, and because the odds that your vote will make any difference in the election is microscopic, then it might be reasonably said that learning and thinking about all of that, just for the purpose of casting a more informed vote might not make sense. Added to all that is the fact that even if you learn what a candidate proposes and promises there is no way to know if he'll actually follow through on those ideas or even try. The real incentive to know these things is the desire to know them for its own good, or to take part in discussions about them if that interests you. If neither of these things means much to someone, I can see why they would remain relatively ignorant. OTOH, if they are consciously and deliberately following the rationally ignorance plan then you would think they would also rationally refrain from voting. Not only because the vote is unlikely to effect the election, but also because if they realize that they are ignorant than even if they do somehow manage to swing the election, how do they know they swung it in the right way? But most people who do remain relatively ignorant for this reason probably don't do so as part of a plan or as a consious deliberate choice. Also voting has other returns for many people beyond the tiny possibility that their vote could help put a good leader or good policies in place. Some view it as an obligation, others do because it helps them feel part of the political group they identify with.