Translucence, III

#2: Interesting points...

Submitted by hgstern on Sun, 07/30/2006 - 1:07pm.

Part of the problem is that buying health care is more akin to buying airline tickets than Big Macs. That is, folks on the same flight (almost) all pay different amounts for the same tickets. Some pay $100 buying from Travelocity, others pay $125 from PriceLine, and some pay $75 from Orbitz (or whatever; no endorsement stated or implied).

Whereas, we all pay $2.29 for the Big Mac (or whatever).

That's kinda the beauty behind both Aetna's plan (and others, of course): folks can look up a specific doc and see how much that flu shot's gonna cost -- ahead of time. And QwikHealth, although not ideal, has the merit of offering its services much more in the McDonald's model than USAir's.

I disagree that it's "a mess;" it's simply the free market trying to work.

Now, if you want to see a "mess," look at England's NHS.

#3: "Free" market is not accurate

Submitted by Dr. Rob Lamberts on Mon, 07/31/2006 - 2:00pm.

If it were a free market, then I could set my prices to match my services. As it stands, I am forced to accept what is being paid or be left out completely. The involvement of third-party payors, especially the government, makes the market an unnatural thing. That is why the market is unable to respond to the escelation of cost and the lack of real quality.

When a cardiovascular surgeon can make $1.1 million per month while the average salary for family physicians is $130,000 there is a problem. This is a system that sets strange values on things. I get less for a newborn resuscitation than the OB/GYN gets for doing the circumsision on the newborn. There are many examples of third-party fee schedules that are just crazy. They set the market, not the physicians.

Rob

Augusta, GA

New Websites:

#4: Perhaps it would help...

Submitted by hgstern on Mon, 07/31/2006 - 2:52pm.

to step back, and examine your argument:

No provider is "forced" to accept any level of remuneration. A provider may choose to participate in a network, in order to maximize potential clientele. Providers are even able to skirt Medicare pricing, by the simple expedient of choosing not to accept it (Medicare).

The example you gave - a surgeon vs a PCP - is simply the most basic free market function at work: supply and demand.

I don't make as much as Fred MacMurray did in his heyday, either: there are a lot more insurance agents than movie/TV stars.

Third parties may "set the market," but that is because the market encourages them to do so.

(Aside: Is there some way to disable these infernal italics?)

#5: Yes, I do make choices

Submitted by Dr. Rob Lamberts on Mon, 07/31/2006 - 5:02pm.

Of which contracts to accept and which to not, but if I am to survive as a smaller practice, I must accept contracts that I have great distaste for. You are right in saying that I am not "forced" to accept the contract, but I am forced to choose between accepting a poor contract or either getting out of medicine or radically changing my practice (i.e. Boutique style of practice).

I do not question whether a CV surgeon should have a higher salary than a family MD, but the degree of the dichotomy is evidence that there are non-market forces at work here (i.e. the infuence of the AMA on the setting of reimbursement codes by Medicare). Medicare actually sets the benchmark for most of these procedures and the insurance companies follow. I agree that the market encouraged the insurance companies to be there in the first place, but I don't agree that their continued existence in the market is simply "free market." There is a lot of strong-arm politics, and lobbying that keeps them there (the same is true for Pharma, by the way, which is clearly protected from the "free market").

My quibble is not whether there are market forces at work to sustain the system as it is, I just think that there are plenty of other forces at work causing the system to spin out of control (with cost becoming a major issue for everyone). I really feel this is more anagous to what Teddy Roosevelt faced with the Railroads and Standard Oil. The market had broken down at that point due to lack of legal control over big corporations. While there are no monopolies like there were in those days, the cost of the third-party segment is very high and the two basic players in the equation, the patient and the doctor, have very little say over what the cost and payments are.

Rob

Augusta, GA

New Websites:

#6: Well, there are always...

Submitted by hgstern on Mon, 07/31/2006 - 10:08pm.

"other forces at work." But the bottom line is, we all make choices that (we hope) maximize our income.

Let's take your example (again): the CVS (no pun in 10 did) vs the PCP. You're unhappy with the disparity in incomes. Nothing wrong with that. But then you go on to say that the dichotomy is ipso fact proof of " non-market forces at work."

On what do you base this? Barry Bonds makes a gazillion dollars playing baseball (okay, maybe he's not the greatest example extant, but work with me here), whereas last year's Dragon's* Rookie of the Year makes a paltry $300k (or whatever). Is this proof of "non-market forces at work?" Of course not: Bonds brings in the fans (whatever that says about the fans), while the rookie doesn't. Or the CEO's salary vs the junior clerk's. It's what the market dictates. Income disparity is not, in and of itself, proof of anything except the value that person brings to the table.

Or is perceived to: same thing.

Network pricing agreements may be influenced by Medicare reimbursement rates, but they are set by the carriers (and/or MCO's), who negotiate with those providers. Again, this is the free market trying to assert itself.

I think your RR analogy is flawed: while there are certainly carriers which dominate a market, they are by no means a monopoly, and they are heavily regulated.

You have no idea how much it pains me to defend carriers, BTW.

*The Dayton Dragons, that is.

#7: I just object to the word "free"

Submitted by Dr. Rob Lamberts on Tue, 08/01/2006 - 3:19am.

They are markets, and the idea of the "free market" at work is one that I do understand. I just think it oversimplifies it to say that this is simply the "free" market at work. It is not just that, there are many other forces (which you admit). Sometimes we are not critical enough and the carriers fall behind the defense of it as being "just the market at work" when there are things wrong going on. Those "other forces" should be dealt with.

Even so, the "free" market did cause the RR monopolies to happen, but despite that fact Roosevelt did the right thing to fight them. The same can be said for the inequities within healthcare. You seemed to imply that because the market caused something, then we don't have cause to want to change it. I disagree with that opinion.

I also feel it is a sign of the sickness of our society that school teachers are so underpaid. Yes, the market has caused this, but I still am frustrated at it. I am critical at our society for the glorification of actors and atheletes - I see it as a wrong. I understand the forces that have done it, but I don't like the fact that our society has such values. Why is hitting a ball so much more than showing care for kids? Surely it is not wrong to speak out against this mentality.

Rob

Augusta, GA

New Websites:

#8: Maybe the free market is an illusion

Submitted by Steve Beller PhD on Tue, 08/01/2006 - 8:03am.

According to Frances Lappe’, in her book “Democracy’s Edge,” there is no free market. She writes:

“In complex societies like ours, markets that work to create wealth for all are the product of democratic governments. The market depends on truly representative government—an obvious point that is lost on those who see the market and government in eternal battle.

Also, a market can be organized in various ways, but here we’ve been taught that there’s only one way: Make business decision using a single criterion—maximize return to shareholders. So every decision returns wealth to people who already have it. … Why would anyone be surprised that the richest 1 percent of American households now control more wealth than the bottom 95 percent combined? … The theory … is that all this results in lower prices for everyone and from this society benefits. … ‘What is really does benefit is a select few who know how to play the game while it threatens almost everyone else.’

The truth is, the market depends on us—on our acting as citizens to create the conditions for it to work.” … But for the past thirty years, we’ve heard a particularly strident and insistent countermessage of the antidemocratic current: ‘Taming the market is un-American’.” (64-65)

With this in mind, I share Rob’s angst that our society’s priorities and principles are screwed up, and the healthcare crisis (along with many others) is due in large part to our misdirected focus and foolish beliefs.

Steve Beller, PhD
http://wellness.wikispaces.com

#9: Well, obviously...

Submitted by hgstern on Tue, 08/01/2006 - 2:09pm.

We're going to have to agree to disagree. There is no "healthcare crisis," for one thing.

For another, our "priorities and principles" are what they are. Folks would rather have a new car every 2 years, digital cable and large-screen LCD TV's but balk at paying a few hundred dollars a month to insure (and ensure) that they can keep them.

That alone is evidence enough of a free market economy well at work.

But hey, at least we have these internet tubes, right?

#10: Look at the evidence

Submitted by Steve Beller PhD on Wed, 08/02/2006 - 5:58am.

Here's proof that there's a healthcare crisis: http://wellness.wikispaces.com/The+Current+Situation

If certain of our priorities and principles don't change, the US will continue its slide into second-rate nationhood.

#11: Interesting article...

Submitted by hgstern on Wed, 08/02/2006 - 11:30am.

I glanced through it (I'll give it a more thorough read-thru when I get a few extra minutes).

At first glance, I see a lot of things which I already knew, some things which are intriguing (if true), and a few oversimplifications.

What I didn't see was any kind of comprehensive solution. BTW, a number of little (or even some major), disparate problems in nominally related areas does not, ipso facto, equal "crisis."

OTOH, this is turning out to be a much more enlightening discussion than some of our previous forays, no?

Have a great afternoon!